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HomeMy WebLinkAboutFour One Productions} NOTE: All payme, I L�!, II'"" -- ME VW01M, 3o/v3 /Completed application /$100 nonrefundable application fee pub liability insurance policy Certificate of insurance that evidences a p or still covering the town as an additional insured in the amount of $ ,000,C►00 cov g Per occurrence for the duration of the filming (one million dollars) p photography. the applicant agrees to assume all indemnification agreement stating pp free for and will indemnify and hold the town harmless b less of an reason o n of liability es that occur to persons or Property y from any and all damag said filming or still photography. completed application to Chief of Police for approval or Forward comp pp disapproval and determination if Traffic Control Fee is require _ Approved Disapproved No Fee Required �QQD,required Fee in the amount of $�� 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): ,-- Film Fee - $100 per day of each day covered by the permit certified check for $250 for each day covered Clea nu deposit: Separate p p by the permit. covered by the permit if required Traffic control fee - $1000 for each day be required by by the Chief of Police. NOTE:Additional funds fee will be expended prior to Police if it is determined that $ 1000 per day the termination of the permit period. f� { �1 4 Beach Parking fee - $10 per vehicle, per day between May 1 and September 30. ISSUED PERMIT Countersign application Issue permit with name of applicant, locations(s), date(s), and time(s) NOTIFICATION of ISSUED PERMIT C hief of Police C Chief Building Inspector Fire Marshal —Z 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. Town of Southold, New York - Payment Voucher Vendor Tax ID Number or Social Security Number Vendor Address 1517 W 35th St 4th FI Vendor Name I New York NY 10001 Four One Productions Vendor Telephone Number Vendor Contact Invoice Invoice Invoice Net Purchase Order Number I Date I Total Discount Amount Claimed I Number Oct -031 6/4/031 700.00 1 I 700.00 Payee Certification The undersigned (Claimant) (Acting on behalf of the above named claimant) does hereby certify that the foregoing claim is true and correct, that no part has been paid, except as therein stated, that the balance therein stated is actually due and owing, and that taxes from which the Town is exempt are excluded. Signature Title _ Company Name Vendor No. of Goods or Services Refund for Traffic Control for Film Permit 10-2003 Department Certification 1 hereby certify that the materials above specified have been received by me in good condition without substitution, the services properly performed and that the quantities thereof have been verified with the exceptions or discrepancies noted, and payment is approved. Signature Title ate �ss�— MEMORANDUM TA• I=inda rtiop�Depety T-ewri-GEer-k -- — _ ___ FROM: Chief Carlisle E. Cochran, Jr. DATE: June 4, 2003 RE: Filming Permit No. 10-2003 - Four One Productions The actual cost for the police detail with reference to Permit No. 10-2003 is 30 Date: 06/05/03 Town Of Southold P.O Box 1179 Southold, NY 11971 * * * RECEIPT * * * Receipt#: 710440347 Transaction(s): Subtotal 1 Traffic Control Fee $1,000.00 Check#: 710440347 Total Paid: $1,000.00 Name: Four, One Productions 517 W 35th St 4th Floor New York, NY 10001 Clerk ID: LINDAC Internal ID: 76352 0 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 June 4, 2003 CERTIFIED MAIL RETURN RECEIPT REOUESTED Four One Productions 417 W 35" St, 4' Fl New York NY 10001 Dear Sirs: Town Hall, 53095 Main Road P.O. Box 1179 Southold, New York 11971 Fax (631) 765-6145 Telephone (631) 765-1800 southoldtown. northfork. net Enclosed herewith is a copy of the cost statement from Chief Cochran of the Southold Town Police concerning the Traffic Control fee for the filming that took. place on April 30, 2003 in Southold Town. A total of $1000.00 was collected for the Traffic Control fee, but only $300.00 was actually required. A refund check of $700.00 will be issued within the month. Also returned herewith is the $250.00 Cleanup deposit. Very truly yours, C U c 3 H Q N D N Q 8 m c J L. c m U O W N N 0 a U to C 0 U 2 a 0 C 0 O U- CM 0 0 N O r O E L N a rn C N o V Ln > W j it _ O ~ V W cc Z O U- D D p O O M tr H U c 3 H Q N D N Q 8 m c J L. c m U O W N N 0 a U to C 0 U 2 a 0 C 0 O U- CM 0 0 N O r O E L N a rn C N .m G ui Q" j it ri Ln Ln O U- 0 Ln p O m M .m -o Q. Q" j it ri Ln Ln Ln Ln p O m M tr Ir .... �.�'• Pu TU w p C7 C3 C] C] _--"' - C3 0 I= o IC -3 C3 o 0 !�T r - Postage Postage Certified Fee Return Receipt Fee (Endorsement Required) Restricted Delivery Fee (Endorsement Required) Total Postage & Fees Recipients Name (Please Print Clearly) (to be completed by mailer) FOLD ------------------------------------ -- --- -----iox N -- - ------------------- Street, Apt. No.; or PO Box No. yc� �� y/ 7 w= 3 S 'r*--------- �---- City, State, ZIP+4 . a L -f . I 100,521, ■ Complete items 1, 2, and 3. Also complete item 4 if Restricted Delivery is desired. ■ Print your name and address on the reverse so that we can return the card to you. ■ Attach this card to the back of the mailpiece, or on the front if space permits. 1. Article Addressed to: 0144 )OR ovC4 c7-/,aiv c V/ -7 GrJ 99A St -41H F4 N Y N `f /000' - A. Received by (Please Print Clearly) I B. D C. Signature X If YES, enter delivery address below: 3. Service Type ET -Certified Mail ❑ Express Mail ❑ Registered ❑ Return Receipt foi ❑ Insured Mail ❑ C.O.D. 4. Restricted Delivery? (Extra Fee) 2. Article Number (Copy from service label) 7000 oG oo Dozy &a57 PS Form 3811, July 1999 Domestic Return Receipt 102 POLICE DEPAQTMENT TOWN OF (SOUTHOLD Telephone Emergency Dial 911 TO: FROM DATE: RE: CARLISLE E. COCHRAN, JR. Chief of Police MEMORANDUM RECEIVED JUN 4 2003 Linda Cooper, Deputy Town Clerk Southold Town Clerk Chief Carlisle E. Cochran, Jr. June 4, 2003 Filming Permit No. 10-2003 - Four One Productions The actual cost for the police detail with reference to Permit No. 10-2003 is $300.OQ. 41405 Route 25 • P.O. Box 911 • Peconic, N.Y. 11958 Administrative (631) 765-2600/2601 • Fax (631) 765-2715 Town Of Southold P.O Box 1179 Southold, NY 11971 ***RECEIPT*** Date: 06/05/03 Receipt#: 710440347 Transaction(s): Subtotal 1 Traffic Control Fee $1,000.00 Check#: 710440347 Total Paid: $1,000.00 Name: Four, One Productions 517 W 35th St 4th Floor New York, NY 10001 Clerk ID: LINDAC Internal ID: 76352 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 PERMIT Issued to: FOUR ONE PRODUCTIONS Location(s), Time(s) and Date(s) WEDNESDAY, APRIL 30, 2003 A, 4:30 PM TO 7:00 PM ROUTE 25, ORIENT between Ferry and Causeway (Driving Scene) Permit No. 010 Issue Date: 3/30/03 a 7 2?� Elizabeth A. Neville Southold Town Clerk (Town Seal) Town Of Southold P.O Box 1179 Southold, NY 11971 ***RECEIPT*** Date: 04/30/03 Receipt#: 0 Transaction(s): Subtotal 1 Daily Filming Permit $100.00 Cash Total Paid: $100.00 Name: Four, One Productions 517 W 35th St 4th Floor New York, NY 10001 Clerk ID: LINDAC Internal ID: 74142 Date: 04/30/03 Transaction(s): Name: Town Of Southold P.O Box 1179 Southold, NY 11971 ***RECEIPT*** 1 Application Fee - Non -Refund Check#: 710440349 Four, One Productions 517 W 35th St 4th Floor New York, NY 10001 Receipt#: 710440349 Total Paid Subtotal $100.00 $100.00 Clerk ID: LINDAC Internal ID: 74141 ELIZABETH A. NEVILLE TOWN CLERK REGISTRAR, OF VITAL STATISTICS MARRIAGE OFFICER RECORDS MANAGEMENT OFFICER FREEDOM OF INFORMATION OFFICER 0�0MIfFO(�►coG s� CIO Z oy� • O�� 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: April 30, 2003 Re: Filming Permit No. 010 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 FOUR ONE PRODUCTIONS. See following pages for a copy of the permit and application. ELIZABETH A. NEVILLE TOWN CLERK REGISTRAR OF VITAL STATISTICS MARRIAGE OFFICER RECORDS MANAGEMENT OFFICER FREEDOM OF INFORMATION OFFICER Town Hall, :53095 Main Road P.O. Box 1179 Southold, New York 11971 Fax (631) 765-6145 Telephone (631) 765-1800 OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD FAX TRANSMITTAL To: Pat Garsik - STPD From: Linda J. Cooper, Deputy Town Clerk Dated: April 18, 2003 Re: Film Permit Number of Pages (including cover): 4 If total transmittal is not received, please call 631-765-1800. COMMENTS: Here is a copy of the issued permit, the application, and insurance. At the bottom of the application are cell phone numbers for Tom and Rory in case you need to contact someone there. Both will be on location for the entire shoot. TOWN 0F SOUTHOLD APPLICATION FOR >~ ILMZNG/STILL PHOTOGRAPHY »PPLICAITZON DATE: (� `_ t J PBMXT NO: or ABFLICi►LiT t 'rely �R.O Qy 0Aj xs:srra ADuaB►aa: J ('l w 3S r` ca' —. F'ba FLS. PiCoxE: Bva,as L,tiSDs- $o(�o t'2 �R%2r —�S9 1 NAAW OF O'R+i7 VIZATION, coleAft ctwr*-C'rr' r..' ( &F, - N4 t oOoZ �tcxE, glya: 2 t2 t +y—I+I�}IT����rrr�J�Mq�11NMY�rtf�r ry wM kw wir^rw*rrr.r.rRW Mr�ww�wf ery r+err DROCA=16 1YP8 pP ACTTVZTY (e.g, UQtiou Picture, cortat,ercial, Television, catalog, magazine, 6 Tl pN �l C''tU R'Qr— VXTZ(8) Xmm Tx�(e) or lr)to"999 Ftr�exera/FBOROGRAPxY: �-©PoSr ti L✓-ra.-v-- dam+ RTZS ea►fir 1,r _- P"POSAb LOCNTT0140; OF FILKZV@/VXOTVQ HYDtach sddttional mbeet, it neceeeary, i�T �- FAL`( T A t. L- 0 a '6rd 6'j R -r. 2J5 , Pot ) ✓rte !�/o MAIM or psReax at C9il7tOE AT a=r»4 .1.d]2ny `.)!K0= MyMa"p- og FE"091t AT LOCATION (dL2T & carie INCTA D19D) WYMSHR ANL TYPE or "a=ez.Ea AT ZOOCATro>e= '5Tq , orb 3 S rh e-. f �v-&A 6'— �� V 1 (I'�` bl r-� � � V C..�LS � / C' %1'►�P6��g'/ L�f 3 C L N �/�f✓" s � zG r �%b �Z,s�� Rte-- fmrt DIL) bw -1a 1 IF�'►� b/t-r[sh+y�� y 716 fDi� CSS 'rX?li OF 83►SeZA.L 8pU=2la8tr; A" "PECTAL► MdDU+TTBe T'�'K-rYi i 7Z&-ry-- ,C_ C�c.d �n foie r ✓ rN �, sK a,� 9 �,g:nature Return to: Southold Town Clerk SbUthold Town Hall 53095 Main Road l P. 0. Box 1179 2 Southold, NY 11971 b0 'd 8S: T T SOOZ 6Z jdH 90OZZ8ZTS�9T: xPd SNOIiDnGOad 3NO dAOd Note to file: Before issuing permit I checked with PD for approval. Since everything was done at last minute I didn't get a chance to transmit along the usual channels. Spoke with Pat Garsik. She checked and the Chief approves, he just needs to know the location they will use and what time. Rory Celentano (location staff) has agreed to call PD %2 hour ahead of time to have PD there for the street shoot. Sometime between 4:30 to 7:00 Cooper, Linda From: Garsik, Pat Sent: Tuesday, April 29, 2003 8:46 AM To: Cooper, Linda Subject: FW: film Is this the info you need? -----Original Message ----- From: Cochran, Carlisle Sent: Tuesday, April 29, 2003 7:09 AM To: Garsik, Pat Subject: film Let linda know that I spoke to Tom Yaeger. He wants to film tomarrow 4/30/03 from 1500 to 1900. 1 think we can help him. He also knows that we may still be in court and have a problem. he is to start with linda and call me in the morning. ACORD CERTIFICATE OF LIA'BILI'TY INSURANCE 4IRA .3D"°m' PRODUCER SeRal MARSH USA, INC. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLbER. THIS CERTIFICATE DOES NOT AMEND EXTEND OR 1166 AVENUE OF AMERICAS ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. NEW YORK, NY 10038. INSURERS AFFORDING COVERAGE INSURRo INBURERA: /%MCrw-1%& %m nVIY1G rw.lv�nr�vc FOUR ONE PRODUCTION% LLC„ & FOCUS FEATURES INSUWB: AIG 417 CANAL STREET, 4tH FLOOR INSURER c; NEW YORK, NY 10013 INSURZRD: I. INSURER E: THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FORTHE POLICY PERIOD INDICATED. N01WITHSTANDING ANY REWAREWNT, 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. AGOREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IN T^rPYOFINSURANCE FOUCYNUM NR MEW DaIwo LIMITS A OENW►L LIAR RM X coMMGRkGENERALLIABILITY aAIM9 MADE ® OCCUR 612-83-84 111/03 111/04 BAN OCCURRENCE S 2,006,60C FIRE DAMAGE (My ams 1m) i r r MED EXP (ABY eta P@+) S PMMNAI. A ADV ULURY f 2,000,00C GENMLACRCI GATE 8 2,000,OOC. WXL AGGREGATE pU�MpIT,APPLIE13 PER POLICY JILT UOG PRODUCTS-COIIE'IOp Afla i 2,0 0, OOC A AUTOMOBILRLNpLJTY ANY AUTO ALLOWNEDAUT08 SCHEDULEDAUrOS HIRED AUTOS • NON GNMED AUTOS COMP/COLLISION Om=SLE:$2504M7-(Par 534-07-17 (AOS) 534-97-18 (MA) $34-97-18 (TX) 534-97.20 (VA) 1/1/03 111/03 1/1/03 1/1103 111104 1/1104 1/1104 111/04 COMBINED BINEDSINGLELIMIT s 1,000,000 BODILY INJURY Twp"-) f BODILY INJURY (Par smidwo ; PROPERTYDAMAM i -ddw4 aAPACE LIABILTIY 4ANYAUTO,. AUTO ONLY -•EAACCIDENT i �� EAACC i wm N.Y AGO i B EXCESS LLML1TY OCCUR cLAiwa MADE DEDUCTIBLE RETENTTok 0 BE7540739 711/02 7/1/03 EACH OCCUPROIM f r AOMOATE s 0( s f = VYORKER& COMPiNSATION AM EMPLOYERS' LIABILITY ER 19.1, EACH ACCIDENT i E.L. DISEASE - EA EMPLOYEE f F.L. DIBE41SE- POLICY LIMIT i OTHGR 0E9CRIPTIOM OF O NWWCA110NWVRMCLWIEXCLUBIDNS ADDED BY ENOOReEMENTISPECIAL PROVISIONS CERTIFICATE HOLDER IS NAMED AS ADDITIONAL INSURED AS REPECTS LIABILITY ARISING OUT OF THE OPERATIONS OF THE NAMED INSURED IN CONNECTION WITH THE PRODUCTION ENTITLED " DOOR IN THE FLOOR! CERTIFICATE HOLDER I I AmmoNAL INsvmc; INsup6R LETTER: The Town Of Southold Southold Town Hall 53095 Main Road PO Box 1179 Southold, NY 11971 C:1FM P RO\CERTPROS. W EB S�0'd ZS:TT S�OOZ 6Z JdH CANCELLATION SHOULD ANY OFTNEABOVE DESCRI99D POLICIES BE CANCELLED 15000'MS EXPIRATIC DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO wwL 30 DAYe YMRrm NOTICE TO THE CERTIFK.ATE HOLDER NAMED TO THE LEFT, SLIT FAIWRII TO 00 80 SHAI IMPOSE NO OSLJOATION OR LIABILITY•OP ANY KIND UPON THE INWRER, ITS AOENT3 C 900218ZT29T: XPJ SNOI10(1QOad ONO dAOO 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. 30/0 �Pr t, C 4 +qvto Printed name tv co-T" Title APPLICANT'S CHECKLIST FOR FILMING PERMIT. NOTE: All payments must be cash or certified check. Completed application $100 nonrefundable application fee 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. 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. Permit Fees (Prior to issuance of permit): Film Fee - $100 per day of each day covered by the permit i� Cleanup deposit: Separate 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, 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 army be required at the direction of the Chief of Police and Superintendent of Highways ZO'd ZS: ZZ MOZ 6Z .add 90OZZ8Zti29Z:XPJ SNOI10f1Q0dd 3NO �1f103 ACORD CERTIFICATE OF LIABILITY INSURANCE D/YY> 4MMD PRODUCER Serial# POLICY NUMBER MARSH USA, INC. 1166 AVENUE OF AMERICAS ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. NEW YORK, NY 10036. INSURERS AFFORDING COVERAGE INSURED INSURER A: AMERICAN HOME A.5SURAN(;F- FOUR ONE PRODUCTIONS, LLC., & FOCUS FEATURES INSURER B: AIG 417 CANAL STREET, 4TH FLOOR INSURER C: NEW YORK, NY 10013 INSURER D: INSURER E: GENERAL AGGREGATE $ 2,000,000 l.0 V tKACstS 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. INUK LTR TYPE OF INSURANCE POLICY NUMBER DATE MMIDDM "DAMMOM LIMITS A GENERAL LIABILITY X COMMERCIALGENERALLMILITY CLAIMS MADE ® OCCUR 612-83-84 1/1/03 1/1/04 EACH OCCURRENCE $ 2,000,000 FIRE DAMAGE (Any one fire) $ 2,000,000 MED EXP (Any one person) $ PERSONAL &ADV INJURY $ 2,000,000 GENERAL AGGREGATE $ 2,000,000 GEWL AGGREGATE LIMIT APPLIES PER POLICY JECOT LOC PRODUCTS - COMP/OP AGG $ 2,000,000 A AUTOMOBILE X X LIABILITY ANY AuTo ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS COMP/COLLISION 534-97-17 (AOS) 534-97-18 (MA) 534-97-19 (TX) 534-97-20 (VA) 1/1/03 1/1/03 1/1/03 1/1/03 1/1/04 1/1/04 1/1/04 1/1/04 COMBINED SINGLE LIMIT $ 1,000,000 (EaaocWent) BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ (Per accident) DEDUCTIBLE: $250/$250 GARAGE LIABILITY ANY AUTO AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ AUTO ONLY: AGG $ B EXCESS LIABILITY X OCCUR CLAIMS MADE DEDUCTIBLE RETENTION $ BE7540739 7/1/02 7/1/03 EACH OCCURRENCE $ 2,000,000— , ,B AGGREGATE s2,000,000 s $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY TORY LIMITS ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS/LOCATIONSIVENCLES/EXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS CERTIFICATE HOLDER IS NAMED AS ADDITIONAL INSURED AS REPECTS LIABILITY ARISING OUT OF THE OPERATIONS OF THE NAMED INSURED IN CONNECTION WITH THE PRODUCTION ENTITLED " DOOR IN THE FLOOR." -- -----••----•.I I A-1IIVrw1.,naUMCU;rnauncKtx11M: vM41%.cwmrrvry The Town Of Southold SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Southold Town Hall DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN 53095 Main Road NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL PO BOX 1179 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR Southold, NY 11971 REPRESENTATIVES. L:1FMI'KU1LtK 1 NKUS. WEB The Door in the Floor FAX -COVER SHEET 2 I DATE: f _ `r ;K r� FAX: TO: FROM: pages Including cover sheet c/o The 8entleY Hotel, Room 29 161 Hill Station Road Southampton, NY 11968 (631) 287.6990 • (631) 287-7006 fax TO'd ZS: TT SMZ 6Z .add 900218ZTS�9T:XPJ SNOI10nGOdd 3NO dnoi