HomeMy WebLinkAboutGregory ScarniciELIZABETH A. NEVILLE
TOWN CLERK
REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER
RECORDS MANAGEMENT OFFICER
FREEDOM OF INFORMATION OFFICER
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
To: Peter Harris, Superintendent of Highways
From: Linda J. Cooper, Deputy Town Cler
Dated: June 25, 2003
Re: Film Permit No. 012 Cleanup Deposit
Town Hall, 53095 Main Road
P.O. Box 1179
Southold, New York 11971
Fax (631) 765-6145
Telephone (631) 765-1800
southoldtown. northfork. net
In accordance with §44A-5 of the Southold Town Code, please advise if the
$250.00 daily Cleanup deposit may be returned to the applicant; if not, please
provide a statement setting forth the actual cost to the town of providing said
cleanup service.
Cleanup was not required at the location(s) identified on the permit. The
deposit may be returned.
Cleanup was required. Actual cost statement is attached.
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ELIZABETH A. NEVILLE
TOWN CLERK
REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER
RECORDS MANAGEMENT OFFICER
FREEDOM OF INFORMATION OFFICER
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
To: Chief Cochran, Southold Town Police
Mike Verity, Senior Building Inspector
Fire Marshal
Ed Forrester, Code Enforcement Officer
Peter Harris, Superintendent of Highways✓
From: Linda J. Cooper, Deputy Town Clerk
Dated. June 2, 2003
,Re: Filming Permit No. 012
Town Hall, 53095 N[ain Road
P.O. Box 1179
Southold, New York 11971
Fax (631) 765-6145
Telephone (631) 765-1800
southoldtown.north.fork.net
In accordance with Town Code 44A-9 you are being notified that a Film Permit
was issued to GREGORY SCARNICL See following pages for a copy of the
permit and application.
July 2, 2003
CERTIFIED MAIL
RETURN RECEIPT REOUESTED
Gregory Scarnici
535 Dean Street
Apt 612
Brooklyn, NY 11217
Dear Mr. Scarnici
Returned herewith is certified check No. 346309121 in the amount of $250.00
that was being held for cleanup fees as required by the Southold Town Code,
Chapter 44A. An inspection of the permit site was made and no cleanup was
necessary.
I hope everything went well with the filming. If I can be of any assistance in the
future, please do not hesitate to contact me.
Very truly yours,
Lynda M Bohn
Deputy Town Clerk
Enc.
***Two Hundred Fifty Dollars,*.,******,.,*****.,t****x**
Not Good For Amounts Over $1,000 - Void if Altered � � ( C;O&-14 S� f n V, 1 )
a
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Remitters Sign t e s' n your name)
a Memo ��e�lvt- �_JL"11V eRMS 535 I�eA,� S1. RrA bt2 (C fyY i►41
f Remitters Address
Issued: by hta7atod Payment Systems Inc, Englewood. Colorado
bank One Colorado N.A.,.Denver, Cplpiado
))'254399))' 1: 1020009791: 2500346309 121911'
�,�� I� soba IS3o oc�3 $33y -71a7
ELIZABETH A. NEVILLE
TOWN CLERK
REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER
RECORDS MANAGEMENT OFFICER
FREEDOM OF INFORMATION OFFICER
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
To: Chief Cochran, Southold Town Police
From: Linda J. Cooper, Deputy Town Clerk
Dated: June 25, 2003
Re: Traffic Control Cost Statement
Film Permit No. 012 — Gregory Scarnici
Town Hall, 53095 Main Road
P.O. Box 1179
Southold, New York 11971
Fax (631) 765-6145
Telephone (631) 765-1800
southoldtown.northfork.net
In accordance with Town Code §44-A paragraph D., a statement regarding the
actual cost to the town of providing traffic control and police officers must be
provided by the Chief of Police. Please provide this information at your earliest
convenience. Thank you.
ELIZABETH A. NEVILLE
TOWN CLERK
REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER
RECORDS MANAGEMENT OFFICER
FREEDOM OF INFORMATION OFFICER
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
To:
Peter Harris, Superintendent of Highways
From:
Linda J. Cooper, Deputy Town Clernp
Dated:
June 25, 2003
Re: Film Permit No. 012 Cleanup Deposit
Town Hall, 53095 Main Road
P.O. Box 1179
Southold, New York 11971
Fax (631) 765-6145
Telephone (631) 765-1800
southoldtown.northfork.net
In accordance with §44A-5 of the Southold Town Code, please advise if the
$250.00 daily Cleanup deposit may be returned to the applicant; if not, please
provide a statement setting forth the actual cost to the town of providing said
cleanup service.
Cleanup was not required at the location(s) identified on the permit. The
deposit may be returned.
Cleanup was required. Actual cost statement is attached.
Signature Date
02/06 '03 MON 14:12 FAX 516 765 6145 SOUTHOLD CLERK
�x* TX REPORT x��a
16tM WYOW113ul W1 3
TX/RX NO
4552
CONNECTION TEL
17185969536
CONNECTION ID
ST. TIME
02/06 14:11
USAGE T
00'50
PGS. SENT
2
RESULT
OK
ELIZABETH A. NEVILLE
TOWN CLERIK
REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER
RECORDS MANAGEMENT OFFICER
FREEDOM OF INFORMATION OFFICER
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
F A X
Q001
Town Hall, 53095 Main Road
P_O. Box 1179
Southold, New York 11971
Fox(631)765-6145
Telephone (631) 765-1800
9outholdtown.northforl-net
To: Paul Regan
From: Lynda Sohn
Re: Filming Permit
Date: June 2, 2003
Pages: 2 including cover
As per instruction from Gregory Scarnici, X am faxing the filming permit to you. I have
also mailed the original to him. Thank you.
f.'
TOWN CLERK'S CHECKLIST FOR FILMING PERMIT
NOTE: All payments must be cash or certified check
Applicant: � M' s
Date Received: I�'lo�l a8 a 60
V Completed application
$100 nonrefundable application fee ✓zk 3% 09122
1/ Certificate of insurance that evidences a public liability insurance policy
covering the town as an additional insured in the amount of $1,000,000
(one million dollars) per occurrence for the duration of the filming or still
photography.
V" Indemnification agreement stating the applicant agrees to assume all
liability for and will indemnify and hold the town harmless of and free
from any and all damages that occur to persons or property by reason of
said filming or still photography.
Forward completed application to Chief of Police for approval or
disapproval and determination if Traffic Control Fee is required
Approved
Disapproved
No Fee Required
Fee in the amount of $ required
Forward certificate of insurance and indemnification agreement to Town
Attorney for approval
Approved
Disapproved
COLLECT FEES AS FOLLOWS:
Permit Fees (Prior to issuance of permit):
V" Film Fee - $100 per day of each day covered by the permit 3�{(030� 122
Cleanup deposit: Separate certified check for $250 for each day covered
by the permit.
Traffic control fee - $1000 for each day covered by the permit if required
by the Chief of Police. NOTE: Additional funds may be required by
Police if it is determined that $1000 per day fee will be expended prior to
the termination of the permit period.
Beach Parking fee - $10 per vehicle, per day between May 1 and
1 September 30.
ISSUED PERMIT
'/ Countersign application
Issue permit with name of applicant, locations(s), date(s), and time(s)
NOTIFICATION of ISSUED PERMIT
Chief of Police
Chief Building Inspector
Fire Marshal
Code Enforcement Officer
Superintendent of Highways
/Superintendent of Parks and Recreation
REQUEST FOR EXTENSION OF PERMIT
Forward extension permit request to Chief of Police
If granted, collect additional $100 per day filming fee
Amend permit to indicate granted extension period
COMPLETION OF PERMIT PERIOD
Chief of Police to provide applicant with statement of cost for providing
Traffic Control and police coverage. (Refund overpayment or collect for
additional costs within 30 days of termination of permit)
Superintendent of Highways inspections locations listed on permit and
determine if cleanup efforts by town personnel is required.
*If cleanup is required, Superintendent will provide Town Clerk
with a statement of actual costs. (Refund overpayment or collect
for additional costs within 30 days of termination of permit)
*If not cleanup is required, Superintendent of Highways will notify
Town Clerk and Town Clerk will remit the $250 certified check to
applicant.
ELIZABETH A. NEVILLE
TOWN CLERK
REGISTRAR. OF VITAL STATISTICS
MARRIAGE OFFICER
RECORDS MANAGEMENT OFFICER
FREEDOM OF INFORMATION OFFICER
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
Town Hall, 53095 Main Road
P.O. Box 1179
Southold, New York 11971
Fax (631) 765-6145
Telephone (631) 765-1800
southoldtown.northfork.net
FILMING/STILL PHOTOGRAPHY
Issued to:
PERMIT
Gregory Scarnici
Location(s), Time(s) and Date(s)
SOUTHOLD TOWN POLICE DEPT., Main Road, Peconic
SUNDAY, JUNE 8, 2003 3:00 PM to 11:00 PM
Permit No. 012
Issue Date: June 2, 2003
Elizabeth A. Neville
Southold Town Clerk
(Town Seal)
ELIZABETH A. NEVILLE
TOWN CLERK
REGISTRAR. OF VITAL STATISTICS
MARRIAGE OFFICER
RECORDS MANAGEMENT OFFICER
FREEDOM OF INFORMATION OFFICER
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
To: Chief Cochran, Southold Town Police
Mike Verity, Senior Building Inspector
Fire Marshal
Ed Forrester, Code Enforcement Officer
Peter Harris, Superintendent of Highways
From: Linda J. Cooper, Deputy Town Clerk
Dated: June 2, 2003
Re: Filming Permit No. 012
Town Hall, 53095 Main Road
P.O. Box 1179
Southold, New York 11971
Fax (631) 765-6145
Telephone (631) 765-1800
southoldtown.northfork.net
In accordance with Town Code 44A-9 you are being notified that a Film Permit
was issued to GREGORY SCARNICI. See following pages for a copy of the
permit and application.
TOWN OF SOUTHOLD
APPLICATION FOR FILMING/STILL PHOTOGRAPHY
PLEASE PRINT OR TYPE
APPLICATION DATE: A S ZL®�_ PERMIT NO: Q I
NAME OF APHLICANT: G(e o' SrC>t`i�1lC;
`
VAILING ADDRESS: 53S pew `�� _ �� (!Ga
%roo' u i Wl IILi7.
PHONE: BUSINESS q11)ZI-.ZCiu�( j' HOME 719• Z30 4bSTo
NAME OF ORGANIZATION, COMPANY: 1 - // i 1IN1S
MAILING AbbwgsS: �'�j� DIPCIV! St.
LW
PHONE: /l0 ' Z_'�io{�� FAX: L ll lOby Z�6
««r+r,r,`r.r•.r.`r+r.ywwwww��..,4f.+*+i..,.#w++«.«.+*r.r..ar*r«.rrrrr.�«r«srr
DESCRIRE TYPE OF ACTIVITY (e. g. MOtiOU picture, Commercial, Television, Catalog,
Magazine, etc.):
MDhem PICA e (56'rfi I�►►)
DATE($) AND TIME(S) OF PROPOSED FILMING/ PHOTOGRAPHY:
Svn a tA,Tine 8 3 n,rh - I I nvvl
PROPOSED LOCATION(S) OF FILMING/PHOTOGRAPHY: attach add' oral sheet, it neceeeary.
O CAA p V6e- 1'M i 4� _ S0(t � � ci ti ! vlc� ��Ilce ►;� } Ci14Gs IZt.ZS
�061 NAME Or PERSON IN CHARGE AT SITE: G� u y • S CC,���� Pe(a(1 C� ►v% y 11 G1 �J3�
NUMBER OF P8UONS AT LOCATION (CAST & CREW 'INCLUDED) : to orb rrt- law y,
SUMER AND TYPE or v"gRICLES AT LOCATION: pL ' Qy►P --ft C 1� 0 1�e J, �• v
TYPE OF SPECIAL EQUIPMENT:
ANY SPECZAi, XZQL11RZHZNTS :
sx a ure
Return to: Southold Town Clerk
Southold Town Hall V,
53095 Main Road
P. O. Box 1179
Southold, NY 11971
POLICE DEPAMMENT
TOWN Of SOUTO,D
Telephone Emergency Dial 911
CARLISLE E. COCHRAN, JR.
Chief of Police
MEMORANDUM RECEIVED
TO: Linda Cooper, Deputy Town Clerk
Southcla T�,,,- Clerk
FROM: Chief Carlisle E. Cochran, Jr. fw
DATE: June 2, 2003
RE: Application for Filming/Still Photography
Hi-Fi Films
As per Local Law No. 6-2001, Section 44A.3, it is the recommendation of the Chief' of
Police that the application dated May 5, 2003, by Hi-Fi Films, be APPROVED.
As per Section 44A.4, Traffic Control Fee, there is NO FEE recommended at this time as
no police assistance will be needed.
41405 Route 25 - P.O. Box 911 - Peconic, N.Y. 11958
Administrative (631) 765-2600/2601 - Fax (631) 765-2715
ELIZABETH A. NEVILLE
TOWN CLERK
REGISTRAR, OF VITAL STATISTICS
MARRIAGE OFFICER
RECORDS MANAGEMENT OFFICER
FREEDOM OF INFORMATION OFFICER
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
F A X
Town Hall, 53095 Main Road
P.O. Box 1179
Southold, New York 11971
Fax (631) 765-6145
Telephone (631) 765-1800
southoldtown. northfork. net
To: Paul Regan
From: Lynda Bohn
Re: Filming Permit
Date: June 2, 2003
Pages: 2 including cover
As per instruction from Gregory Scarnici, I am faxing the filming permit to you. I have
also mailed the original to him. Thank you.
Town Of Southold
P.O Box 1179
Southold, NY 11971
***RECEIPT***
Date: 06/02/03
Receipt#: 346309122
Transaction(s): Subtotal
1 Application Fee - Non -Refund $100.00
1 Daily Filming Permit $100.00
Check#: 346309122 Total Paid: $200.00
Name: Scarnici, Gregory
535 Dean Street
Suite 612
Brooklyn, NY 11217
Clerk ID: LYNDAB
Internal ID: 76178
MEMORANDUM
TO: Linda Cooper, Deputy Town Clerk
FROM: Chief Carlisle E. Cochran, Jr.
DATE: June 2, 2003
RE: Application for Filming/Still Photography
Hi-Fi Films
As per Local Law No. 6-2001, Section 44A.3, it is the recommendation of the Chief of
Police that the application dated May 5, 2003, by Hi-Fi Films, be APPROVED.
As per Section 44A.4, Traffic Control Fee, there is NO FEE recommended at this time as
no police assistance will be needed.
ELIZABETH A. NEVILLE
TOWN CLERK
REGISTRAR. OF VITAL STATISTICS
MARRIAGE OFFICER
RECORDS MANAGEMENT OFFICER
FREEDOM OF INFORMATION OFFICER
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
To: Southold Town Attorney's Office
From: Linda J. Cooper
Dated: 5/28/03
Re: Filming Permit
Town Hall, 53095 Main Road
P.O. Box 1179
Southold, New York 11971
Fax (631.) 765-6145
Telephone (631) 765-1800
southoldtown.northfork.net
In accordance with the Southold Town Code, Chapter 44A, Section 3, Subsection
D, the Certificate of Insurance and Indemnification Agreement for a Filming
Permit Application for Gregory Scarnici by Gregory Scarnici are attached
hereto. Please review and advise whether these documents meet with your
approval. Thank you.
Approved as submitted
Disapprove for the following reasons:
Signature
I have looked into your concerns and have found the following:
1. Film Emporium is the insurance policy provider
2. Mr Gregory Scarnici is not applying for the permit on behalf of Hi-Fi
Films. He has asked that this name be completely taken off the film
application and other related documents and the permit be issued in his
name only.
Date
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
To: Southold Town Attorney's Office
From: Linda J. Cooper
Dated: 5/28/03
Re: Filming Permit
Town Hall, 53095 Main Road
P.O. Box 1179
Southold, New York 11971
Fax (631) 765-6145
Telephone (631) 765-1800
southoldtown.northfork.net
In accordance with the Southold Town Code, Chapter 44A, Section 3, Subsection
D, the Certificate of Insurance and Indemnification Agreement for a Filming
Permit Application for Gregory Scarnici are attached hereto.
Please review and advise whether these documents meet with your approval.
Thank you.
Approved as submitted
Disapprove for the following reasons:
0
ELIZABETH A. NEVILLE
TOWN CLERK
o -
REGISTRAR OF VITAL STATISTICS
ti Z
$ •
MARRIAGE OFFICER
RECORDS MANAGEMENT OFFICER
y�Ipl �•a�
FREEDOM OF INFORMATION OFFICER
�
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
To: Southold Town Attorney's Office
From: Linda J. Cooper
Dated: 5/28/03
Re: Filming Permit
Town Hall, 53095 Main Road
P.O. Box 1179
Southold, New York 11971
Fax (631) 765-6145
Telephone (631) 765-1800
southoldtown.northfork.net
In accordance with the Southold Town Code, Chapter 44A, Section 3, Subsection
D, the Certificate of Insurance and Indemnification Agreement for a Filming
Permit Application for Gregory Scarnici are attached hereto.
Please review and advise whether these documents meet with your approval.
Thank you.
Approved as submitted
Disapprove for the following reasons:
RECEIVED
HI -Fl Films
MAY 2 8 2003 535 Dean Street, Suite 612
Brooklyn, NY 11217
Southold Town Clerk (718) 230-4656 (p)
(212) 664-2485 (f)
May 22, 2003
To Whom It May Concern,
I spoke with Chief Carlisle Cochran, Jr. of the Souhthold Police Department in
regards to filming the "Southold Police Department" sign located at 41405, Route 25 in
Peconic, NY, which is listed on this application form. He told me that before clearance
could be given, I needed to apply for a film license from the Office of The Town Clerk
and he would look into it once the application came across his desk. He informed me to
include a letter stating that we had spoken about this matter with my application form and
fee.
If you have any questions regarding this matter, please do not hesitate to contact me.
Sincerely,
�s ��
'regory Scarnici
Hi-Fi Films
TOWN OF SOUTHOLD
APPLICATION FOR FILMING/STILL PHOTOGRAPHY
PLEASE PRINT OR TYPE
APPLICATION DATE: g01v 5, ZoO3 PERMIT NO:
NAME OF APPLICANT: OC 0`AsC ln\C
VAILING ADDRESS: SSS 17t'cm �r, (0a
PHONE: BUSINESS `li� 72�-.1��1v-� HOME ! IO • Z30- 44 56
N7►ME. OF ORGANIZATION, COMPANY: GCOQIOr� JQ1,r_Y1iCL
MAILING ADDRESS: �� of ci1y)
17Y0(} y, jg� W7
PHONE: Z3e�il FAX-- ZQ ro6�t'Z48S
**.A**.....�**#..*******4.,kl'J�**i..*..***.#**..*.i*..*.****..**.*...
DESCRIS8 TYPE OF ACTIVITY (e.g. Motiop picture, Commercial, Television, Catalog,
Magazine, etc_):
H1D+v,,, 'c!v,e CS�o{fi ►�,)
DATE (8) AND -(TIME (9) OF PPLOPOSED VILMIXG /PHOTOGRAPHY:
SQV% A Inv )J AP � � ' 7 s�.rn - l 1 V) -V1
PROPOSED LOCATION(S) OF FILMING/PHOTOGRAPHY: attach add( Oual ebeet, if neceeeary•
Q 404 P vw� , - SUI d Iv 1�" .Id P"I'. i }. glgoG ' V-t.ZS
NAOF' PERSON IN CHARGE AT SITE: Gv? v �cn`(YIIC, Pe(c I,C/ tv / �l CjsB�
NUMBER OF PERSONS AT LOCATION (CAST & CREW TNCLUDIM) : to
NUMBER AND TYPE or v£HICLES AT LOCATION: 0M-NvX one
TYPE OF SPECIAL EQUIPMENT!
ANY SPECTAL 3iSOT71AEMi1'rNTH;
silwaeure
Return to: Southold Town Clerk
Southold Town Hall
53095 Main Road
P. O. Box 1179
Southold, NY 11971
INDEMNIFICATION AGREEMENT
TOWN OF SOUTHOLD
FILMING/STILL PHOTOGRAPHY PERMIT
The Applicant shall indemnify and hold harmless the Town from and against all
suits, claims, demands or actions for any damage and;or injury sustained or alleged
to be sustained by any party or parties in connection with the performance of
filming or still photography by the Applicant, his employees or agents or any
subcontractor and in case of any such action brought against the Town, the
applicant shall immediately take charge of and defend the same at his own cost and
expense. In addition, the Applicant will name the Town as an additional insured on
any applicable policies.
G- oeLIUM s v b
Printe e
D►reClcqt 6, er,-
Title
t
ACORD. CERTIFICATE OF LIABILITY INSURANCE
��'"""°°""YY'
o5n2noo3
PRODUCER
Film Emporium, Inc.
274 Madison Ave 1204
NY NY 10016
teW 212 683 2433
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
INSURERS AFFORDING COVERAGE NAIC #
INSURED
Gregory Scamici
535 Dean Street Apt 612
Brooklyn NY 11217
INSURER A: St Paul Fire and Marine Insurance
INSURER 8:
INSURER C:
INSURER D:
INSURER E:
IKe1`/ZI:I_lei Zk1
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
RISK
ADW.
TYPEPOLICY
POLICY NUMBER
EA1EtMFFEwTIVE
POLICY EXPIRATION
LIMITS
GENERAL LIABILITY
REPRESENTATIVES.
EACH OCCURRENCE $ 1,000,000
A
AUTHORIZED REPRESENTATIVE
Film Emporium, Inc.
X COMMERCIAL GENERAL LIABILITY
CK04500736-1677
06/05/2003
06/09/2003
$50,000
CLAIMS MADE � OCCUR
MED EXP (Arty one person) $5,000
PERSONAL S ADV INJURY $1.000,000
GENERAL AGGREGATE $2.000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMP/OP AGG $1,000,000
POLICY F1PRO- LOC
AUTOMOBILE LIABILITY
ANY AUTO
COMBINED SINGLE LIMIT S -
(Es accident)
BODILY INJURY =
(Per person)
ALL OWNED AUTOS
SCHEDULED AUTOS
BODILY INJURY
(Per accident) S
HIRED AUTOS
NON -OWNED AUTOS
PROPERTY DAMAGE _
(Per accident)
GARAGE LIABILITY
AUTO ONLY - EA ACCIDENT S
OTHER THAN EA ACC S
ANY AUTO
AUTO ONLY: AGG S
EXCES&VMMPNRAALIABILITY
EACH OCCURRENCE S
AGGREGATE $
OCCURCLAIMS MADE
S
$
DEDUCTIBLE
S
RETENTION S
WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
TOR Y I .IT R
ANY PROPRIETOR/PARTNER/EXECUTIVE
E.L. EACH ACCIDENT $
OFFICERIMEMBER EXCLUDED?
E.L. DISEASE • EA EMPLOYE S
H ea, desaibe under
I
E L. DISEASE - POT ICY LIMIT $
OTHER
OF OPERATIONS / LOCATIONS / VEHICLES/ EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL
PDESCRIPTION
The certificSate holder is named as additional insured as their interests may appear.
vcrc r rrra.P%r r- nvLJCM
6AIM6CLLA I IU M
Town of SOuhold
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
53095 Main Rd
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN
Southold, NY 11971
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
REPRESENTATIVES.
-
AUTHORIZED REPRESENTATIVE
Film Emporium, Inc.
1988
__ -A
A90611. CERTIFICATE OF LIABILITY INSURANCE
DATE (MM/DD/VVYY)
05/22/2003
PRODUCER
Film Emporium, Inc.
274 Madison Ave #204
NY NY 10016
tele* 212 683 2433
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
INSURERS AFFORDING COVERAGE NAIC #
INSURED
Gregory Scamici
535 Dean Street Apt 612
Brooklyn NY 11217
INSURER A: St Paul Fire and Marine Insurance
INSURER B:
INSURER C:
INSURER D:
INSURER E:
nnv�sen_e•a`
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
MR
LTR
NSR
TYPE OF INSURANCE
POLICY NUMBER
OLIO EFFECTIVEL
DATE MM/DDlYY
EXPIRATION
DATE MM/DD/YY
LIMITS
GENERAL LIABILITY
EACH OCCURRENCE S1,000,000
PREMISES Ea ocourence $50,000
A
X COMMERCIAL GENERAL LIABILITY
CK04500736-1677
06/05/2003
06/09/2003
CLAIMS MADE F� OCCUR
MED EXP (Any one person) $5,000
PERSONAL i ADV INJURY $1,000,000
GENERAL AGGREGATE s2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMP/OP AGO $1,000,000
POLICY PRO LOC
JECT
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT
S
ANY AUTO
(Ea accident
BODILY INJURY
S
ALL OWNED AUTOS
SCHEDULED AUTOS
(Per person)
BODILY INJURY
S
HIRED AUTOS
(Per accident)
NON -OWNED AUTOS
PROPERTY DAMAGE S
(Per accident)
GARAGE LIABILITY
AUTO ONLY - EA ACCIDENT $
OTHER THAN EA ACC S
ANY AUTO
AUTO ONLY: AGG S
EXCESS/UMBRELLA LIABILITY
EACH OCCURRENCE S
AGGREGATE S
OCCUR D CLAIMS MADE
i
S
DEDUCTIBLE
S
RETENTION S
WORKERS COMPENSATION AND
TORY LIMITS ER
E.L. EACH ACCIDENT $
EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE
E.L. DISEASE- EA EMPLOYEE S
OFFICER/MEMSER EXCLUDED?
Ir yes, descltsel-, der
E.L. DIBEABE-'POIK:Y LIMIT i
SPECIAL PROVISIONS'beleer
OTHER
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL
PROVISIONS
The certificate holder is named as additional insured as their interests may appear.
CERTIFICATE HOLDER CANGELLATIUN
Hardy Plumbing, Htang 8 AC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES RE CANCELLSOMFORE TV& EXPIRATION.
13501 Main Rd DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN
Mattituck NY 11952 NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
Film Emporium, Inc.
ernRn 74 i7nnimm I AC RD CiMPORATI N 1988
i4CORD. CERTIFICATE OF LIABILITY INSURANCE
12 SIM"'°°""'"'
0522/2003
PRODUCER
Film Emporium, Inc.
274 Madison Ave #204
NY NY 10016
tele# 212 683 2433
THIS CERTIFICATE 13 ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
INSURERS AFFORDING COVERAGE NAIC #
INSURED
Gregory Scamici
535 Dean Street Apt 612
Brooklyn NY 11217
INSURER A: St Paul Fine and Marine Insurance
INSURER B:
INSURER C:
INSURER D:
INSURER E:
n%2n w n_&0
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. -
INISR
AWL
TYPE OF INSURANCEMIDWM
POLICY NUMBER
POLK:YMEFFECTIVE
POLICY EXPIRATION
LIMITS
GENERAL LIABILITY
EACH OCCURRENCE $1.000.000
DAMAGE TO
PREMISES (Es occurenc $50,000
A
X COMMERCIAL GENERAL LIABILITY
CK04500736-1677
06/05/2003
06/09/2003
MED EXP (Any one person) $5,000
CLAIMS MADE D OCCUR
PERSONAL & ADV INJURY $1,000,000
GENERAL AGGREGATE $2,000,000
GENT AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMP/OP AGG $1,000,000
POLICY PRO- LOC
JECT
AUTOMOBILE 11ABI1 ITY
ANY AUTO
COMBINED SINGLE LIMIT
(Ea acciderd) f
BODILY INJURY f '
(Per person)
ALL OWNED AUTOS
SCHEDULED AUTOS
BODILY INJURY
(Per scclderd) f
HIRED AUTOS
NON -OWNED AUTOS
PROPERTY DAMAGE f
(Per accident)
GARAGE LIABILITY
AUTO ONLY - EA ACCIDENT f
OTHER THAN EA ACC f
ANY AUTO
AUTO ONLY: AGG f
EXCESSIUMBRELLA LIABILITY
EACH OCCURRENCE f _
AGGREGATE f
OCCUR EDCLAIMS MADE
f
f
DEDUCTIBLE
RETENTION S
WORKERS COMPENSATION AND
VATU 'Tt
Y
E.L. EACH ACCIDENT f
EMPLOYERS LIABILITY
IETORIP
E.L. 01 ASE -EA EM 9
�XXECUTIVENO
E.L. DISEASE -POLICY LIMIT f
B yes, describe under
SPECIALR VII I
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL
PThe" erti to holder is named as additional insured as their interests may appear.
Southold Police Department SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
41405 Rte 25 DATE THEREOF, THE ISSUING INSURER WALL ENDEAVOR TO MAIL 30 DAYS WRITTEN
Peconic NY 11958 NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
Film Emporium, Inc.
Ar-nnn 29 MnnvnR1 ACOR ON 1988
9x/ns 'ns wFn nA,27 FAX 516 765 6145 SOUTHOLD CLERK
TX REPORT �c
TRANSMISSION OK
TX/RX NO
4544
CONNECTION TEL
7342315
CONNECTION ID
Police Administ
ST. TIME
28/05 09:24
USAGE T
02'14
PGS. SENT
7
RESULT
OK
ELIZABETH A. NEYILLE
TOWN CLERK
REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER
RECORDS MANAGEMENT OFFICER
FREEDOM OF INFORMATION OFFICER
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
To: Cbief Cochran, Southold Town Police
From: Linda J. Cooper, Deputy Town, Clerk
Dated: 5/28/03
Re: Filming Pemit
Q001
Town Hall, 53095 Main Road
P.O. Box 1179
Southold, New York 11971
Fax (631) 765-6145
Telephone (631) 765-1800
southoldto w n_northfork.net
Transmitted herewith is the application of Iii -FY Films by Gregory Scarnici for a
Filming Permit. 1n accordance with Section 44A.3 of the Town. Code please
review the application and advise of approval or disapproval of the application
and whether a traffic control fec is required and the amount needed.
ELIZABETH A. NEVILLE
TOWN CLERK
REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER
RECORDS MANAGEMENT OFFICER
FREEDOM OF INFORMATION OFFICER
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
To: Southold Town Attorney's Office
From: Linda J. Cooper
Dated: 5/28/03
Re: Filming Permit
Town Hall, 53095 Main Road
P.O. Box 1179
Southold, New York 11971
Fax (631) 765-6145
Telephone (631) 765-1800
southoldtown.northfork.net
In accordance with the Southold Town Code, Chapter 44A, Section 3, Subsection
D, the Certificate of Insurance and Indemnification Agreement for a Filming
Permit Application for Hi-Fi Films by Gregory Scarnici are attached hereto.
Please review and advise whether these documents meet with your approval.
Thank you.
Approved as submitted
Disapprove for the following reasons:
Signature
Date
ELIZABETH A. NEVILLE
TOWN CLERK
REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER
RECORDS MANAGEMENT OFFICER
FREEDOM OF INFORMATION OFFICER
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
To: Chief Cochran, Southold Town Police
From: Linda J. Cooper, Deputy Town Clerk
Dated: 5/28/03
Re: Filming Permit
Town Hall, 53095 Main Road
P.O. Box 1179
Southold, New York 11971
Fax (631) 765-6145
Telephone (631) 765-1800
southoldtown.northfork.net
Transmitted herewith is the application of Hi-Fi Films by Gregory Scarnici for a
Filming Permit. In accordance with Section 44A.3 of the Town Code please
review the application and advise of approval or disapproval of the application
and whether a traffic control fee is required and the amount needed.
RECEIVED
MAY 2 8 2003
Southold Town Clerk
May 22, 2003
To Whom It May Concern,
HI -F! Films
535 Dean Street, Suite 612
Brooklyn, NY 11217
(718) 230-4656 (p)
(212) 664-2485 (f)
I spoke with Chief Carlisle Cochran, Jr. of the Souhthold Police Department in
regards to filming the "Southold Police Department" sign located at 41405, Route 25 in
Peconic, NY, which is listed on this application form. He told me that before clearance
could be given, I needed to apply for a film license from the Office of The Town Clerk
and he would look into it once the application came across his desk. He informed me to
include a letter stating that we had spoken about this matter with my application form and
fee.
If you have any questions regarding this matter, please do not hesitate to contact me.
Sincerely,
�e'g�o�rySc-amici
Hi-Fi Films
INDEMNIFICATION AGREEMENT
TOWN OF SOUTHOLD
FILMING/STILL PHOTOGRAPHY PERMIT
The Applicant shall indemnify and hold harmless the Town from and against all
suits, claims, demands or actions for any damage an d!or injury sustained or alleged
to be sustained by any party or parties in connection with the performance of
filming or still photography by the Applicant, his employees or agents or any
subcontractor and in case of any such action brought against the Town, the
applicant shall immediately take charge of and defend the same at his own cost and
expense. In addition, the Applicant will name the Town as an additional insured on
any applicable policies.
Vv2' , Jin ib
Printe e
D1- ie C W / 'Rvo kce4
Title
ACORD. CERTIFICATE OF LIABILITY INSURANCE
/22/20 MIDD/YYYYI
o5n2noo3
PRODUCER
Film Emporium, Inc.
274 Madison Ave $204
NY NY 10016
telO 212 683 2433
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
INSURERS AFFORDING COVERAGE NAIC 0
INSURED
Gregory Scamid
535 Dean Street Apt 612
Brooklyn NY 11217
INSURER A: St Paul Fine and Marine Insurance
INSURERS:
INSURER C:
INSURER D:
INSURER E:
^nen: o w r_C0
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
Town of SOuhold
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
POLICY NUMBER
POLICY EFFE :TfVE
IN
POLICY EXPIRATIONIt
WOCOM
LIMITS
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
GENERAL LIABILITY
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
EACH OCCURRENCE $1,000,000
$50,000
PREMISES (Es ocwrence)
A
X COMMERCIAL GENERAL LIABILITY
CK04500736-1877
06/05n003
06/09n003
MED EXP (Any one person) $5,000
CLAIMS MADE D OCCUR
PERSONAL d ADV INJURY $ 1,000,000
GENERAL AGGREGATE $2,000,000
FGEN1. AGGREGATELIMIT APPLIES PER:
PRODUCTS - COMPIOP AGG $1,000,000
POLICY PRO LOC
AUTOMOBILE I LABILITY
ANY AUTO
COMBINED SINGLE LIMIT
(Es scddent) $
BODILY INJURY
(Per person) _
ALL OWNED AUTOS
SCHEDULED AUTOS
BODILY INJURY
(Per accident) :
HIRED AUTOS
NON -OWNED AUTOS
PROPERTY DAMAGE S
(Per scddenf)
GARAGE LIABRJTY
AUTO ONLY - EA ACCIDENT S
OTHER THAN EA ACC S
AW AUTO
AUTO ONLY: AGG i
aC011111 16UAMLFTY
EACH OCCURRENCE $
AGGREGATE $
OCCUR CLAIMS MADE
S
$
DEDUCTIBLE
S
RETENTION S
WORKERS COMPENSATION AND
,!T R
E.L. EACH ACCIDENT f
EMPLOYERS' LIABILITY
ANY PROPRIETORIPARTNERIEXECUTIVE
E.L. DISEASE - EA E=2YE
OFFICERIMEMBER EXCLUDED?
E.L DISEASE - POLK Y LIMB i
Ues, mbo de under
IALEPR below
OV
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL
P�OVI
The cert' to holder is named as additional insured as their interests may appear.
CERTIFICATE HOLDER
cA141Ut1.LA I ICJM
Town of SOuhold
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
53095 Main Rd
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN
Southold, NY 11971
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
REPRESENTATIVES
AUTHORIZED REPRESENTATIVE �
Film Emporium, Inc. // I-
w
SIJ
ACO -L CERTIFICATE OF LIABILITY INSURANCE
/22/20DATE M/DD/YYYY)
05/22/2003
PRODUCER
Film Emporium, Inc.
274 Madison Ave #204
NY NY 10016
tele# 212 683 2433
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
INSURERS AFFORDING COVERAGE NAIC #
INSURED
Gregory Scamici
535 Dean Street Apt 612
Brooklyn NY 11217
INSURER A: St Paul Fire and Marine Insurance
INSURER B:
INSURER C:
INSURER D:
INSURER E:
%1 V Y G1{AV &0
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
LTR
NSR
TYPE OF INSURANCE
POLICY NUMBER
POLICYIC
DATE MMIDD/YY
1 ON
DATE MMIDDIYY
LIMITS
GENERAL LIABILITY
EACH OCCURRENCE $1,000,000
PREMISES Es occurencs $50,000
A
X COMMERCIAL GENERAL LIABILITY
CK04500736-1677
06/05/2003
06/09/2003
MED EXP (Any one person) s5,000
CLAIMS MADE D OCCUR
PERSONAL 6 ADV INJURY S1,000,000
GENERAL AGGREGATE s2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMP/OP AGO $1,000,000
POLICY PRO- LOC
JECT
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT f
(Es accident)
ANY AUTO
BODILY INJURY f
ALL OWNED AUTOS
(Per person)
SCHEDULED AUTOS
BODILY INJURY $
HIRED AUTOS
(Per accident)
NON -OWNED AUTOS
PROPERTY DAMAGE f
(Per accident)
GARAGE LIABILITY
AUTO ONLY- EA ACCIDENT f
OTHER THAN EA ACC f
ANY AUTO
AUTO ONLY: AGG f
EXCESS/UMBRELLA LIABILITY
EACH OCCURRENCE S
AGGREGATE 3
OCCUR D CLAIMS MADE
f
S
DEDUCTIBLE
S
RETENTION S
WORKERS COMPENSATION AND
TORY LIMITS ER
E.L. EACH ACCIDENT f
EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNERIEXECUTIVE
E.L. DISEASE- EA EMPLOYEE f
OFFICERIMEMBER EXCLUDED?
E.L Dise iE-'POLICY LIMIT T
If yes, desafM undw
SPECIAL PROVISIONS Setet►
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL
PROVISIONS
The certificate holder is named as additional insured as their interests may appear.
CERTIFICATE HOLDER CANCELLATION
He* Pkmd)iM HtBaft & AC SHOULD ANY OF THE ABOVE DESCRMED POLICIES BE CANCELLED i/iOWATNE BX114"T10M,
13501 Main Rd DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS wRvrTEN
Mattituck NY 11952 NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO 30 SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
Film Emporium, Inc.
1988
mi
ACORD,, CERTIFICATE OF LIABILITY INSURANCE
/DATE 22/20 MIDD/YYY1�
o5n2/2oo3
PRODUCER
Film Emporium, Inc.
274 Madison Ave #204
NY NY 10016
tele# 212 683 2433
THIS CERTIFICATE 13 ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
INSURERS AFFORDING COVERAGE NAIC #
INSURED
Gregory SCamici
535 Dean Street Apt 612
Brooklyn NY 11217
INSURER A: St Paul Fire and Marine Insurance
INSURER 8:
INSURER C:
INSURER D:
INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE OLEN REDUCED BY PAID CLAIMS.
INSIR
ADDFL
NSRE
TYPE OF INSURANCE
POLICY NUMBER
POLICY EFFUCTIVE
POLICY EXPIRATION
LIMITS
GENERAL LIABILITY
EACH OCCURRENCE $1,000,000
DAMAGE TO $50,000
urencel
JA
X COMMERCIAL GENERAL LIABILITY
CK04500736-1677
06/05/2003
06/09/2003E
CLAIMS MADE D OCCUR
MED EXP (Any one person) $5,000
PERSONAL & ADV INJURY $1,000,000
GENERAL AGGREGATE $ 2,000,000
GEML AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMPIOP AGG $1,000,000
POLICY PRO LOC
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT
:
ANY AUTO
(Es accident)
BODILY INJURY
ALL OWNED AUTOS
SCHEDULED AUTOS
(Per person) =
BODILY INJURY =
HIRED AUTOS
NON -OWNED AUTOS
(Per accident)
PROPERTY DAMAGE S
(Per accident)
GARAGE LIABILITY
AUTO ONLY - EA ACCIDENT S
OTHER THAN EA ACC $
ANY AUTO
AUTO ONLY: AGG S
EXCESSNMBRELLA LIABILITY
EACH OCCURRENCE $
-I
OCCUR F CLAIMS MADE
AGGREGATE $
S
i
DEDUCTIBLE
S
RETENTION S
WORlf8R8 COMPENSATION ANDTORY
LIMITS
E.L. EACH ACCIDENT i
EMRMVNWLLAOLM
ANIr PROPRiET�Oq�A�IVE
EL01OME-EA EMR S
0�.
Syes, describe under
E.L. DISEASE -POLICY LIMIT I S
OTHER
DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL
O'v1
he cert' tate holder is named as additional insured as their interests may appear.
CERTIFICATE HOLDER CANCELLATION
Southold Police Department
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
41405 Rte 25
DATE THEREOF, THE ISSUING INSURER MILL ENDEAVOR TO MAIL 30 DAYS WRITTEN
Peconic NY 11958
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
REPRESENTATIVES. '-7/1
Film Emporium, Inc.
A
1988
k
■ ■ ■ ■ ■ ■
THE VAHIA L;L F- TONE BACKGROUND AREA OF THIS DOCUMENT CHANGES COLOR GRADUALLY AND SMOOTHEN FROM DARKER TONES AT DOTH TOP AND BOTTOM TO THF l IG HTEST TONE IN THE MIDDLE
1162S43990 ■ ■ ■ --
THE VARIABLE TONE BACKGROUND AREA OF THIS DOCt MENT CHANGES COLOR GRADUALLY AND SMOOTHEN FROM DARKER TONES AT BOTH TOP AND BOTTOFd 70 THE LIGHTEST TONE IN THE MIDDLE.
APPLICANT'S CHECKLIST FOR FILMING PERMIT
NOTE: All payments must be cash or certified check.
✓ Completed application
$100 nonrefundable application fee
4 Certificate of insurance that evidences a public liability insurance policy
covering the town as an additional insured in the amount of $1,000,000
(one million dollars) per occurrence for the duration of the filming or still
/ photography.
V Indemnification agreement stating the applicant agrees to assume all
liability for and will indemnify and hold the town harinless of and free
from any and all damages that occur to persons or property by reason of
said filming or still photography.
Pen -nit Fees (Prior to issuance of permit):
V/
Film Fee - $100 per day of each day covered by the permit
V✓ Cleanup deposit: Separate check for $250 for each day covered by the
permit.
V q Traffic control fee - $1000 for each day covered by the permit if required
by the Chief of Police.
h&I Beach Parking fee - $10 per vehicle, per day between May 1 and
September 30.
ALL CHECKS MUST BE CERTIFIED
NOTE: Additional fees for Cleanup and Traffic Control may be required at
the direction of the Chief of Police and Superintendent of Highways
�Srj