HomeMy WebLinkAboutVoice in the Head ProductionsX
TOWN ULr-Rn %;F ---
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
anthe on of the fount Of ilming or00ill
(one million dollars) per occurrence for the
photography -
Xing stating the applicant agrees to assume all
Indemnification agrd the town harmless of and free
liability for and will indemnify and hold b reason of
from any
and all damages that occur to persons or property Y
said filming or still photography-
,------completed
hotography.
/Forward completed application to Chief of Police for approval or
disapproval d determination if Traffic Control Fee is require
Approved
Disapproved
a/ No Fee Required required
Fee in the amount of $
ce and indemnification agreement to Town
Forward certificate of insuran
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
Cleanup deposit: Separate certified check for $250 for each day covered
by the permit.
Traffic control fee - $1000 for each day covered by the bpermit
required byired
by the Chief of police. NOTE: Additional fu may
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
September 30.
ISSUED PERMIT
Countersign application
A' Issue permit with name of applicant, locations(s), date(s), and time(s)
NOTIFICATION of ISSUED PERMIT
A[,, I Chief of Police
-� Chief Building Inspector
vvt Fire Marshal
4-�= 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
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
December 26, 2002
CERTIFIED MAIL
RETURN RECEIPT REQUESTED
Rita Romagnino
Voice in the Head Productions
41 W 85th St, Apt 4B
New York NY 10024
Dear Ms. Romagnino:
Town Hall, 53095 Main Road
P.O. Box 1179
Southold, New York 11971
Fax (631) 765-6145
Telephone (631) 765-1800
southoldtown.northfork.net
Returned herewith is certified check No. 325594416 in the amount of $500 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,
4"c&j 6&070�
—
Linda J. Cooper
Deputy Town Clerk
Enc.
7000 6(,vv �vay 3vs� �i�3
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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: Peter Harris, Superintendent of Highways
From: Linda J. Cooper, Deputy Town Clerk
Dated: December 23, 2002
Re: Film Permit No. 009 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
RECEIVED
D EC 2 6 2002
Southold Town Clerk
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.
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: Peter Harris, Superintendent of Highways
From: Linda J. Cooper, Deputy Town Clerk
Dated: December 23, 2002
Re: Film Permit No. 009 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
Cooper, Linda
From: Garsik, Pat
Sent: Thursday, December 12, 2002 3:38 PM
To: Cooper, Linda
Subject: Film crew - Dan Tresca
Linda ... Dan Tresca called wanting to reschedule his filming from Sat and Mon to Fri and Mon. I spoke with the Chief and
he has no problem with this switch. Dan was requesting due to inclement weather on Sat ... Any problem let me know as I
have to call Dan back..Thanks..Pat
ELIZABETH A. NEVILLE
TOWN CLERKcm
REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER
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THE TOWN CLERK
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
ALL PHOTOGRAPHY
ERMIT
E
P.M.
;002 from 7:00 A.M. to 7:00 P
Teen Pike St and Main Ri
Elizabeth A. Neville
Southold Town Clerk
(Town Seal)
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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
Forrester, Code Enforcement Officer
Peter Harris, Superintendent of Highways
From: Linda J. Cooper, Deputy Town Clerk
Dated: December 4, 2002
Re: Filming Permit No. 009
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 VOICE IN THE HEAD 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
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
To: Chief Cochran
From: Linda Cooper
Dated: December 4, 2002
Re: Film Permit
Town Hall, 53095 Main Road
P.O. Box 1179
Southold, New York 11971
Fax (631) 765-6145
Telephone (631) 765-1800
southoldtown. northfork. n et
As requested, here are cell phone numbers for emergency contact at the time of
filming.
Set cell phone: 917-459-4564
Dan Tresca: 631-806-7246
• Town Of Southold •
P.0 Box 1179
Southold, NY 11971
(631) 765-1800
RECEIPT
#009a
Voice, In The Head Productions
(contact Dan Tresca)
41 W. 85th St Apt 4b
New York, NY 10024
12/04/2002
Received $ 200.00 for Daily Filming Permit, on 12/04/2002. Thank you for stopping by the Town
Clerk's office.
As always, it is our pleasure to serve you.
Neville
Clerk
Elizabeth A.
Southold Town
0 •
POLICE DEPAQTMENT
TOWN OF 6OUTOLD CARLISLE E. COCHRAN, JR.
Chief of Police
Telephone Emergency Dial 911
MEMORANDUM
RECEIVED
TO: Linda Cooper, Deputy Town Clerk NOV 2 $- 2002
FROM: Chief Carlisle E. Cochran, Jr.
Southold Town Clerk
DATE: November 22, 2002
RE: Application for Filming/Still Photography
As per Local Law No. 6-2001, Section 44A.3, it is the recommendation of the Chief of
Police that application dated November 20, 2002, by Voice in the Head Productions, be
APPROVED.
As per Section 44A.4, Traffic Control Fee, there is NO FEE recommended at this time as
there is no need for police assistance.
A cell phone number is required from the applicant for emergency contact at the time of
filming.
Set e""/1 Pb°ne,
41405 Route 25 • P.O. Box 911 • Peconic, N.Y. 11958
Administrative (631) 765-2600/2601 • Fax (631) 765-2715
0 0
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: Chief Cochran
From:
Linda Cooper, Deputy Town Clerk
Dated:
November 20, 2002
Re:
FILMING PERMT
Number of Pages (including cover): 2
If total transmittal is not received, please call 765-1800.
COMMENTS:
Received an application for a filming permit for December 14 and 16 in Mattituck. You hard
copy is in inter -departmental mail.
•
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
From: Linda J. Cooper, Deputy Town Clerk
Dated: 11/20/02
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 Voice in the Head Productions by
Dan Tresca 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.
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: 11/20/02
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 Voice in the Head Productions by Dan Tresca are
attached hereto. Please review and advise whether these documents meet with
your approval. Thank you.
-4�;7 Approved as submitted TT F- C 0 f/- 1, � - v- j
1i F--
NOV 20 2002
TOWN ATTORNETS OFFICE
TOWN OF SOUiHOLD
Disapprove for the following reasons:
Signature
Date
RECEIVED •
TOWN OF SOUTHOLD
NOV 2 0 2009
APPLICATION FOR FILMING/STILL PHOTOGRAPHY
Southold Town Clerk ^� PLEASE PRINT OR TYPE y
APPLICATION DATE: 0®—o a PERMIT NO: Q O
NAME OF APVtICANT: e -S GCA,
NAILING ADDRESS.-
PHONE:
DDRESS:
PHONE:
BUSINESS 6,?/
L40 G 7d(/{
HOME
NAME OF
ORGANIZATION,
COMPANY:
1 , C- 9
�N J -e
I %
L C "' d LL S
MAILING ADDRESS: Vy
/ie.j V.,rl A1Y 100.2
PHONE: ()�- yrs' PAX:
DESCRIBE TYPE OF ACTIVITY (e.g, Motion picture, Commercial, Television, Catalog,
Magazine, etc.):
_Iva �1'0 h �IA t�L (�- 40 r-�
DATES) AND TIME(S)(F PROPOSED VILMIXG/PHOTOGRAPHY: \
ca
PROPOSED LOCATION (S) OF FILMING/PHOTOGRAPHY: attach additional abeet, if neceiaary.
'L"I4 .h /�Of- i8e P -L'-
NAME OP' PERSON IN CHARGE AT SITE: ► ^O. c,, VY�CRCk,—: ,n 6
NUMBER OF PBASONS AT LOCATION (CAST & CREW INCLUDED):
NUi33SR AND TYPE or vESYcLUS AT LOCATION: q -
TYPE OF SPECIAL EQUIPMM*T:
ANY SPECXAL REQVIRZKONTS.
xgnature J
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.
-11"-X O� -vrt-S
Printed name
Y, r
Ccx v\ r
'title
AC. o
CERTIFICATE OF LIABILITY INSURANCE DATE(MMipp"W)
PROOuOilt
11/18/2002
Flim Emporium, Inc,
I
THIS CERTIFICATE 1 ISSUED AS AA MA OF INFO TION
ONLY AND CONFERS NO RN) UPON T"IS CERTIFICATE
274 Madison Ave
MOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
NY NY 10016
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW,
taiell 212 Bea 2439
_
INSURERS AFFORDING COVERAGE MAIC aK
MINI
Rita Rompnino
INSURER A: St, Paul Fire and Marine Insuranca
INSURER B, Underwriters at LIDyd'a
41 Well 85th Street Apt 48
NY NY 10024
INSURER C:
I
(Neuman 0: '—
COVERAGES
INSURER E:
_
THE POLICIES OF INSURANCE LISTED 13E -LOW HAVE SEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTNATNSTANDING
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WTH RESPECT TO VVHICli THIS CERTIFICATE MAY B6 ISSUED OR
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES. AQGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,
NZR AW. -
6M to — rog-OF-lammNOR POLICY NUMBER Y Elf T N LIMITS
OlNEML LUWLITY EACH OCCURRENCE 61.000,0 0
AX COMMERCIAL GENERAL LIABILITY CK04500738-1417 12104=02 12/16/2002
UA
a $ 50,000
CLAIMS MADE OCCUR MED EXP om 5,000
OEN'L AGGREGATE LIMIT APPLIES PER:
POLICY F7 PR - ML
ALI MOBILa LIABILITY
ANY AUTO
ALL OWNED AUTOS
SCHEOULEDAUTOS
HIRED AUTOS
NON -OWNED AU708
GARAGE LumLITY
ANY AU TO
EXCESWUMBRELLA LIABILITY
OCCUR GLAIMB MADE
DEDUCTIBLE
RETENTION I
WORKERS COMPENSATION AND "^
EMPLOYBRB' LIAaiLnY
ANY PROPRIETORIPARTNERlEXECUTIVE
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OTHER TVDp3836 12104/2002
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2. 3rd Party Property Dsmape
iEBCRRuIroPTNNIO••N OF OPERATIONS I LOCATIONS / VENICLEE t EXCLUSIONEADDOD BY ENOd18EMENT I SPECIAL
M GeRi4cate Holder la named as Additional Insured and Lose Payee as their Interests may appear.
k
COMBINED LIMIT
SHOULD ANY or TNR ABOVE OPEC FUSED POLICIES BE CANCELLED BEFORE THa EXPIRATIOr1
tSINGLE
(64 �.
B
BODILY NJJURY
NOTICE TO THE CERTIFICATE 401-0EIR NAMED TO THE LEFT, BUT FAILURE TO DO 90IIHALL
(P�r PYfiOfll
f
BODILY INJURY
REPRESENTATIVES.
(PLr aoddwt)
AUTNORKEC RBPREBENtATIVi i.
PROPERTYDAMAOE
Fllm Emporium, Inc,
1Per widen)
RD TION III$
AUTO ONLY • EA ACCIDENT
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OTHER THAN EA ACC
AUTO ONLY'
f
E.L. Oi9EASE • EA EMPLOYE 6 w
�� E.L. DISEASE . POLICY LIMIT
12/16/2002 1. Llmlt; $500,000 Deductible, $^ 2,600
2 Limit; $250,000 Deductible: $2,500
Southhoid Town Hall v -
SHOULD ANY or TNR ABOVE OPEC FUSED POLICIES BE CANCELLED BEFORE THa EXPIRATIOr1
53005 MBin Rd.
DATE THEREOF, THE ISSIJINO INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN
PO 80X 1179
NOTICE TO THE CERTIFICATE 401-0EIR NAMED TO THE LEFT, BUT FAILURE TO DO 90IIHALL
Southhold, NY 11971
IMPOSE NO OBLIGATION OR LIABILITr OF ANY KIND UPON THE INSURER, ITE AGENT= OR
REPRESENTATIVES.
AUTNORKEC RBPREBENtATIVi i.
ACORD 04110
Fllm Emporium, Inc,
RD TION III$
` •
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GREGORY F. YAKABOSKIQS �CD
JOSHUA Y. HORTON
45N
Supervisor
TOWN ATTORNEY Gy
C
Town Hall, 53095 Route 25
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P.O. Box 1179
KATHLEEN MURRAY O
Southold, New York 11971-0959
Telephon(631765-1939
ASSISTANT TOWN ATTORNEY �Ol
�aO�
email
greg.yakaboski@town.southold.ny.us
PATRICIA A. FINNEGAN
kathleen.murray@town.southold.ny.us
ASSISTANT TOWN ATTORNEY
patricia.finnegan@town.southold.ny.us
OFFICE OF THE TOWN ATTORNEY
TOWN OF SOUTHOLD
Fax Transmittal Sheet
TO: Jon Shearin
Roy H. Reeve Agency Inc.
FROM: Gregory F. Yakaboski, Esq.
Town Attorney
RE: Filming Permit — Voice in the Head Productions
DATE: November 25, 2002
Jon:
Voice in the Head Productions has requested a filming permit from the Town of
Southold for the period December 14 through December 16, 2002. A copy of their
Certificate of Liability Insurance follows together with their application for permit. Please
review and advise if this is the appropriate coverage.
Thank you.
Greg
/md
Pages, including cover
Phone no.: 631-765-1939
Fax no.: 631-765-1823
Fax to: 298-3850
Phone no.: 298-4700
P. 1
* COMMOCATION RESULT REPORT ( NOV-25-200 2:27PM ) * * *
FAX HEADER: SOUTHOLD SUPERVISORS
TRANSMITTED/STORED : NOV,25.2002 2:25PM
FILE MODE OPTION ADDRESS RESULT PAGE
---------------------------------------------------------------------------------
---------
194 MEMORY TX 2983850 OK 4/4
---------------------------------------------------------------------------------------------
REASON FOR ERROR E-2) BUSY
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j0Sj1UA Y. MORTON
G}REGIORY F. Ys>¢ssaOS�[ guFFOZ& Supervisor
TOWN ATTORNEY _
Town hall, 65095 Route 26
P.O. Boz 1179
RATI7I�E1�T Southold, New York 11-198 969
Telephos:e C681) 785-1989
ASSTSTAN"Y TOWN ATTORNEX �. a -mail:
gregyeYaboslai�ttosvn.sautbold.ny.us
PATRICIA A. 3@`Xr4_NMGtAN kathleerL=urray(IDtown.southold.nY.uft
ASSISTANT TOWN ATTORNEY patricia.9.aaeganCDt�owa-southold.ny.ua
OFFICR OF WiLxe TOWN AT'T)rORN ISS
TOWN OF SOUTII01,3D
Fax Transmittal Sheet
TO: Jon Shearin
Roy H. Reeve Agency Inc.
FROM: Gregory F. Yakaboski, Esq.
Town Attorney
RE: Filmina Permit — Voice In the Head Pr
DATE: November 25, 2002
.fon:
Voice in the Head Productions has requested a filming permit from the Town of
Southold for the period December 14 through December 16, 2002. A copy of their
Certificate of Liability Insurance follows together with their application for permit. Please
review and advise if this is the appropriate coverage.
Thank you.
Greg
Jmd
Pages, including cover _
Phone no.: 631-765-1939
Fax no-, 631-765-1823
Fax to: 298-3850
Phone no.: 298-4700
11126/2002 04:21 5165822200 LADY COACH PAGE 02
11/23/2992 15:13 212-683- FILM EMPORIUM PAGE 01
11
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00"" TO TM oww"rl IIOLMIR "ANMD /0 Till WrT, pit IAIW}MI 70 A so OW
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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.
� r
rinted name
YCC0'+;0y\ f
,title
ACORD,,,, CERTIFICA OF LIABILITY INSURA E
DATE(MM/DD/YYYY)
11 /18/2002
PRODUCER
Film Emporium, Inc.
274 Madison Ave
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
Rita Romgnino
41 West 85th Street Apt 4B
NY NY 10024
INSURER A: St. Paul Fire and Marine Insurance
INSURER B: Underwriters at Lloyd's
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 BEEN REDUCED BY PAID CLAIMS.
LTR
INSR
TYPE OF INSURANCE
POLICY NUMBER
POLICY EFFECTNE
DATE MM/DD/YY
POLICY EXPIRATION
DATE MM/DD
LIMITS
GENERAL LIABILITY
EACH OCCURRENCE $ 1,000,000
PREMISES 0'T - M rence $ 50,000
A
X COMMERCIAL GENERAL LIABILITY
CK04500736-1417
12/04/2002
12/18/2002
CLAIMS MADE F� OCCUR
MED EXP (Any one person) $ 5,000
PERSONAL 8 ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMP/OP AGG $ 1,000,000
POLICY PRO LOC
JECT
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT
ANY AUTO
(Ea accident) $
BODILY INJURY
ALL OWNED AUTOS
SCHEDULED AUTOS
(Per person) $
BODILY INJURY
$
HIRED AUTOS
NON -OWNED AUTOS
(Per accident)
PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY
AUTO ONLY - EA ACCIDENT $
OTHER THAN EA ACC $
ANY AUTO
E
AUTO ONLY: AGG $
EXCESS/UMBRELLA LIABILITY
EACH OCCURRENCE $
OCCUR CLAIMS MADE
AGGREGATE $
$
DEDUCTIBLE
$
RETENTION $
WORKERS COMPENSATION AND
WUbIAIU- U111 -
TORY LIMITS ER
EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE
E.L. EACH ACCIDENT $
OFFICER/MEMBER EXCLUDED?
E.L. DISEASE - EA EMPLOYE $
If yes, describe under
SPECIAL PROVISIONS below
E.L. DISEASE - POLICY LIMIT $
OTHER
TVDp3636
12/04/2002
12/18/2002
1. Limit: $500,000 Deductible: $2,500
B
1.Misc Equipment
2. Limit: $250,000 Deductible: $2,500
2. 3rd Party Property Damage
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL
PROVISIONS
The Certificate Holder is named as Additional Insured and Loss Payee as their interests may appear.
CERTIFICATE HOLDER CANCELLATION
Southhold SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
Southhold Town Hall DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN
53095 Main Rd. 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
Southhold, NY 11971 REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
Film Emporium, Inc.
A�o,M CERTIFICATE OF LIABILITY INSURANCE
Film Emporium, Inc.
274 Madison Ave
NY NY 10018
1411441212 083 2433
RNs Rompnlno
41 Wiest 8511 Street Apt 49
NY NY 10024
DATE (Mlfift Yy) _
THIS CERTIFICATE ISSUED AS A MATTER OR IMP-0109—TION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
ALTER TH COVERRA43E AFFORDEE NOTTHEEPOLICIES BELOW.
INSURERS AFFORDING COVERAGE MAIC M
INSURSR A: St, Paul Fire and Marine insuranco
IN8uPER B: Underwdters 411 Lloyd's
INSURER C.
INSURER D:
INSURER E:
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWTMSTANDINC
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT NTH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN, THE INSURANCEAFFORDPO BY THE POLICIES DESCRIBED MEREIN IS SUBJECT TO ALL THE TBRIAS EXCLUSIONS ANDCOND T
POLICIES. ApOREtiATE LIMITS SNDINN MAY HAVE BEEN REDUCED BY PAID CLAIMS,
NM Aw
6ML TM OF INSIMN2, POLICY NUMBER y T
GENERAL LAMILITY
A X COMMERCIAL OENERAL LABILITY CK04500738.1417 12!012002 1211=002
CLAIMS MADE F7 OCCUR
GENT AGGREGATE LIMIT APPLIES PER:
POLICY i2 L
FANYAUTO
MOBILE LIABILITY
LI, OWNEOAUTOS
CHEDULED AUTOS
IREo AUTOS
NON -OWNED AUTOS
GARAGE L IAEB,ITY
ANY AU TO
OCCUR � CLAIMS MADE
DEDUCTIBLE
RETENTION $
WORKERS COMPENSATION AND
EMPLOVERS' LUBILITY
ANY PROPRIETORIPARTNERNXECUTIVE
OFMCERIMEMBER EXCLUDED9
g I PAI$G Equipment Ij
------
i
--- I �crwrcuu[
l_2. 3rd Party Property Damage
5E41CRIrnpN OF OPERATN?N$ f LOCATION$! VEHICLES ! aXCLLteIONSADDED ar ENDOIe$ NEMS T 1T l a
� Ov�BKN1
e NotiLate Holder is named as Additional Insured and Lose Payee Be their Interests may appear,
1 IONS OF SUCH
N
IIMm
EACH OCCURRENCE
61.000,000
21tPultal ME coo
`
$50,000
MED EXP ons
5,000
PERS NAL &ACV INJURY
S 1,D00,000
GENERAL AGGREGATE
2,000,000
PRODUCTS -COMPIOPAGO
$1,000,000
COMBINED SINGLE LIMIT
6
(as aacloantj
BODILY INJURY
tPv parwn)
S
BODILY INJURY
=
(P" Wddent)
PROPERTYDAMAGEbwWanq
$
AUTO ONLY • EA ACCIDENT
i
OTHER 74AN EA ACC
AUTO ONLYt AGG
6
EACH OCCURRENCE
t
AGGREGATE
3
S
i
E.L. EACH ACCIDENT
$
F.L. DISEASE • EA EMPLOYE
_
E.L. DISEASE • POLICY LIMIT
S
1. Limit: $500,000 Deducible: $2,500
2. Limit: $250,000 Deductible: $2,6DD
Southhoid TOWn McII
ANOULD ANY OF flit AVE DESCRIBED POLICIES BE CANCELME LED BEFORE TEXPIRATIOI I
530p5 Main Rd.
OATS TNSREOF, THE I3SUING INSURER WILL ENDEAVOR TO MAIL 30 DAY$ NBRITTSN
PC BOX 1178
NOTICE TO THE CERTIFICATE NOLDEIR NAMED TO THE LEFT, SLIT FAILURE TO DO SO $HALL
Southhold, NY 11871
IMPOSE NO OBLIGATION OR LiAS1LITr OF ANY KIND UPON TITS INSURER, ITS AG/NT$ OR
Flim Emporium, Inc, E—,,' �%�/ I
Town Of Southold .
P.O Box 1179
Southold, NY 11971
***RECEIPT***
Date: 11/20/02 Receipt#: 325594414
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Name: Voice, In The Head Productions
(contact Dan Tresca)
41 W. 85th St Apt 4b
New York, NY 10024
Clerk ID: LINDAC
Internal ID: 64196
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na tir
n Of Southold
.O Box 1179
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hold, NY 11971
ECEIPT
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Receipt#: 325594414
Transaction(s):
Subtotal
1
Application Fee - Non-Refund
$100.00
Check#:
325594414
Total Paid: $100.00
Name: Voice, In The Head Productions
(contact Dan Tresca)
41 W. 85th St Apt 4b
New York, NY 10024
Clerk ID: LINDAC
Internal ID: 64196
•
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RECEIVED
TOWN OF SOUTHOLD
NOV 2 0 7;"2
APPLICATION FOR FILMING/STILL PHOTOGRAPHY
Southold Town Omit PLEASE PRINT OR 'TYPE
f a -Co C- APPLICATION BATE: Intl O tx PERMIT NO: I}
�` ���pICA1n1
NAME OF APPLICANT:
MAILING ADDRESS.- �B o vv�ayh: h
o... ,Mass : J�'«pp \
►� -i- e �� : (\moo -1.
PHONE: BUSINESS (d,?/ '1�0 (D 7.)7 b HOME
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ni/ k
NAME ORGANIZATION,
NCOMPANY: r /
MAILING ADDRESS& "7 U3- 4 4
AJe�� A/y looao
PHONE. ( �� 7 O FAX:
#r-i.r -WN*****4.**}rri nifr.++rrwirr.w*.ktr 1-1rr rr�rrrrrsrr
c+1dl-LS,
DESCRIBE TYPE OF ACTIVITY (e.g. Motion picture, Commercial, Television, Catalog,
Magazine, etc.):
f, n, / c t
DATE(S) AND TIM (S) OFrPROPOSZD VILMING/PHOTOGRAPHY:
PROPOSED LOCATION(S) OF FILMING/PHOTOGRAPHY: attach addi,t
abee%tt, if nQeceeea y. y�
keJ
NAME OV PERSON IN CHARGE AT SITE: � 1 Vi 1X— Q
NUMBER OF P2UO1NS AT LOCATION (aKST & CREW INCLUDIM) :
402
NUMBER AND TYPE Or VEHICLES AT LOCATION:
4 -
TYPE OF SPECIAL EQUIPMENT:
ANY SPECZAi, PXQ17'IRZKENTS :
tune
Return to: Southold Town Clerk
Southold Town Hall
53095 Main Road
P. 0. Box 1179
Southold, NY 11971