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HomeMy WebLinkAboutThe Lovely Works LLC Vendor No. Check No. Town of Southold, New York - Payment Voucher Vendor Name Vendor Address Entered by -Tke L6\fel\j Woyks LLC- 1q3 I'iri4on Q}udi1=Tate ' Vendor lITelep oneNumbeerr Q n `'1(V 3 3-1 - LI 1 G`t 1 J roo<<< I I rA(�s Town Clerk 44Ale-Y,{V'eendor C1ontactt" "�YeGe. I Y1 C' 0 Invoice Invoice lnv6.j, Net Purchase Order Number Date Total Discount Amount Claimed Number Description of Goods or Services General Ledger Fund and Accour;t Number- 1500 umber1500 i i Total Payee Certification Department Certification The undersigned(Claimant)(Acting on behalf of the above named claimant) I hereby certify that the materials above specified have been received by me does hereby certify that the foregoing claim is true and correct,that no part has in good condition without substitution,the services properly been paid,except as therein stated,that the balance therein stated is actually performed and that the quantities thereof have been verified with the exceptions due and owing,and that taxes which the Town is exempt are excluded. or discrepancies noted,and approved. Statur TitZ. Signature Company Name Date IO N11 Title Ion 764Ah", Date * * * RECEIPT * * * Date: 09/15/16 Receipt#: 213343 Quantity Transactions Reference Subtotal 1 Application Fee - Non-Refund 045 $10000 2 Clean-Up Deposit 045a $500.00 2 Daily Filming Permit 045b $200.00 Total Paid: $80000 Notes: Payment Type Amount Paid By CK#0200 $800.00 The, Lovely Works Llc Southold Town Clerk's Office 53095 Main Road, PO Box 1179 Southold, NY 11971 Name: The, Lovely Works Llc 193 Clinton Avenue Brooklyn, NY 11205 Clerk ID: LYNDAR Internal ID 045b Southold Town Board - Letter Board Meeting of October 18, 2016 RESOLUTION 2016-928 Item# 5.17 ADOPTED DOC ID: 12348 THIS IS TO CERTIFY THAT THE FOLLOWING RESOLUTION NO. 2016-928 WAS ADOPTED AT THE REGULAR MEETING OF THE SOUTHOLD TOWN BOARD ON OCTOBER 18, 2016: WHEREAS the following groups have supplied the Town of Southold with a Clean-up Deposit for their events and WHEREAS the Southold Town Police Chief, Martin Flatley, has informed the Town Clerk's office that this fee may be refunded, now therefor be it RESOLVED that Town Board of the Town of Southold hereby authorizes a refund be issued in to the following: Name Date Received Amount Can't Forget Productions, LLC 9/19/16 $ 650.00 "Friends From College" 42-2222 nd Street, 3rd Flr,N. Long Island City,NY 11101 The Lovely Works, LLC 9/15/16 $ 500.00 193 Clinton Avenue, Apt 2B Brooklyn,NY 11205 North Fork Lacrosse Club 1/5/16 $ 250.00 415 Village Lane Mattituck,NY 11952 Cutchogue New Suffolk Historical 8/31/16 $ 250.00 Cutchogue Village Green PO Box 714 Cutchogue, NY 11935 Mattituck Presbyterian Church 9/15/16 $ 250.00 Main Road PO Box 1411 Mattituck,NY 11952 Generated October 19, 2016 Page 31 Southold Town Board - Letter Board Meeting of October 18, 2016 Elizabeth A. Neville Southold Town Clerk RESULT: ADOPTED [UNANIMOUS] MOVER: William P. Ruland, Councilman SECONDER:Jill Doherty, Councilwoman AYES: Dinizio Jr, Ruland, Doherty, Evans, Russell ABSENT: Robert Ghosio Generated October 19, 2016 Page 32 0c:: mo � � o�w �ovu, Z� Ow O :'q00 ; z _ ,-.z�-__ ;c to C z To � � o= = D mZ m 2� — Z D O � cn= M mxn C= m � or rC �oCz �_ - - = v z v v �, m a� O -� m 2A O w CD N cfl = n~ n T — � m — rri W O>CD O C Z o0o� ■ 0mom C011- Z Ctf 5 i% 0 V� ZWma y M M o Q � Q s �-4 CD Eq q J1C10760I0407w 544A N53NE8 After printing this label 1 Use the'Pnnt'button on this page to print your label to your laser or inkjet printer 2 Fold the printed page along the horizontal line 3 Place label in shipping pouch and affix it to your shipment so that the barcode portion of the label can be read and scanned Warning,Use only the printed original label for shipping Using a photocopy of this label for shipping purposes is fraudulent and could result in additional billing charges,along with the cancellation of your FedEx account number. 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Address fle]UTAEO priWht ONLYIo Dengomuts.%9rfulciudng drylcel camwtbe shippod in RdExpeckaging - ❑FadE<Prlor o ,at :da opaaadneFee&ExPro Drepeox ❑ Cargo Aircraft Only Use this line for the HOLD location address or for continuhon of your shipping address FedExMoytawlectbcefbns `' ( G 7 Payment algto: City Vlbcskl V r/•1 State & '1 ZIP 1 01025F- ErdarFodFxAcct No.orcredit Cord No.below.Sen � ❑A�jNos1adan %Recipient ❑Third Parry ❑ Credit Card ❑ Cash/Check z 0107057211 rCrexCAdN ribs ©Ig c�b3 T Total Packages Total Weight Total Declared Valuer l°-).aAB L11G11.A1.B5'LYkLLkrCA X11-'�r.A:.lAy r r Iha, S AO 611 tOwgebgmyla fmumdro USSI0O unlessyoudaclereehighorvelue See heckfordalsila By uvngthisAWNyou - 1 1 I 1 agree mane service wirfmore onthe heck otth6Airb11 and NNe cunemfedExSeMca Ouide,includng terms thrtgmrtowBehEay, < < - flay Deta2/12•Pert/183134•®1994-20@FedEx•PRINTED IN U SA SRS Terms and Conditions Summary For the current FedEx Service Guide,which contains the complete Terms a`nd Co'ndition`s,`go'to fiedeir chin' Definitions On this Airbill,"we,""our,""us,"and"FedEx" •We won't be liable t Filing A Claim YOU MUST MAKE ALL CLAIMS IN WRITING refer to Federal Express Corporation,its employees,and agents —for your acts or omissions,including but not limited to' or online at fedex.com and notify us,of ydorc`faim'wttliin strict "You"and"your"refer to the sender,`its employees,and agents improper or insufficient packing,securing,marking,or time limits set out in the current FedEx Service Guide Agreement To Terms By giving-us your package to deliver, addressing','or those of,the recipient or anyone else with You may call our Customer Service department at i ' �1 T you agree to all the terms on this Airbtll and in the current an interest ln•the package 1 80d GbFedEX 1 800 463 9339 to report a'claijri,however, - FedEx Service Guide,which is available at fedex.com or ata you must still file a timely written claim We alren't obligated - , —if you or the recipient violates any of the terms of f FedEx location You also agree to those terms on behalf of any our Ato act on any claim until you have paid all trampprtation third party with an interest in the package If there is a conflict Agreement charges,and you may riot deduct the amount of your claim between the current FedEx Service Guide-and this Airbill,the —for loss of or damage to shipments of prohibited items from those charges 1 current FedEx Service Guide will control No one 1s authorized to —for loss,damage,or delay caused by events we cannot If the recipient accepts your paoVage wrtIf6Ut'noting•ail change the terms of our Agreement control,including but not limited to acts of God,perils of damage on the delivery record,we will assume the package•" Responsibility For Packaging And Completing Airbill the au,weather conditions,acts of public enemies,war, was delivered in good condition For us o process'youJ claim, You are responsible for adequately packaging your goods and strikes;civil commotion's;or acts of public authorities you must make the original shipping cartons`and pack g1 properly filling out this Airbill If you omit the number of with actual"Tapparent authority available for inspection, packages and/or weight per package,our billing will be based Declared Value Limits i'' ( ' L dight 7o Inspect We may,at our option,open and inspect on our best estimate ofxhe number of packages we received our"ackages before or after , our them n, us n deliver and/or an estimated"default"weight per,package as The maximum declared value allowed for a FedEx Envelope or Y P Y 9 determined by us Fed00 {Ex Pak shipment is PS$5 : Right Of Rejection We reserve the right to reject a S 41 wsh1 Responsibility For Payment 'Even if you give us different 6 For other shipments,the raa imum declared valuerallowed is shlpm@,n 4' ,.,hen such pm ent would be hkef Yto cause payment instructions,you will always be primarily responsible for US$50,000 per package,unless your package contains items delay or dargage to other shipments,equipment,or all delivery costs,as well as any cost we incur in either returning of extraordinary,value,in which case the maximum declared personnel,or if the shipment is proliibited by law;or if the your package to you or warehousing it pending disposition value allowerj rq US$1,000 per package shipment wpuld violate b6y-terms of,our Aitbgl qr the current Limitations On Our LiabilityAnd Liabilities- •Items of extraordinary value include shipments containing FedEx Service Guide C.O.D.Services CA D SEPVICEf'IS NOT AVAILABLE WITH Not Assumed ,such items as artwork,jewelry,furs,precious metal's,nego-'_, � , tlable instruments,and other items listed m the cur°r'ent FedEx THIS AIRBILL if C 0•D Servlce r r`egLpred-,pleasd use a FedEx •Unless a higher value is declared and paid for,our liability for Service Guide 1. C 0 D Airbill each package is limited to US$100 You may pay an additional Air Transportation Tax Included A federal excise charge for each additional US$100 of declared value The You may send more than'one package on this Airbill and fill p declared value does not constitute,nor do werovide,caro in the total declared value for all packages,not to exceed tax when required by-the Internal Revenue Code on the air p g the US$500,US$1,000,or US$50,000 per Rackage limit' transportation portion of this service,if any,is paid by us, liability insurance described above (Example 5 packegescan have a total Money Back Guarantee In fheevenl'of untimely delivery, •In any event,we will not be liable for any damage,whether ; declared value of up to US$250,000)In that case,our liability FedEx will,at your request and with some limitations,refund direct,incidental,special,or consequential,in excess of,the is limited to the actual value of,the pac)<ages)lost or damaged, or credit all transportation charges See the current FedEx declared value of a shipment;whether or clot FedEx had - ' but may not exceed the maximum,allowable declared value(s)or Service Guide for more information knowledge that such damages might be incurred,mcludfng the total declared value,whichever is less You are responsible but not limited to loss of income or profits for proving the actual loss or damage Part 163134•Rev Date 2/12 ELIZABETH A. NEVILLE,IV MCTown Hall,53095 Main Road TOWN CLERK y� P.O. Box 1179 CCA Southold,New York 11971 REGISTRAR OF VITAL STATISTICS - _ .tG Fax(631)765-6145 MARRIAGE OFFICER Telephone(631)765-1800 RECORDS MANAGEMENT OFFICER �d www.southoldtownny.gov FREEDOM OF INFORMATION OFFICER OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD FILMING/STILL PHOTOGRAPHY Issued to: THE LOVELY WORKS /Andrea Hetherinl4ton Date(s), Time(s) and Location: Monday, October 3,2016 8:00 am—6:00 pm Tuesday, October 4, 2016 8:00 am—6:00 pm Rocky Point Beach,East Marion,New York Permit No. 045 Issue Date: 9/15/16 Elizabeth A.Neville Southold Town Clerk (Town Seal) ELIZABETH A.NEVILLE,MMC �yQ G� Town Hall,53095 Main Road TOWN CLERK P.O. Box 1179 N ar Southold,New York 11971 REGISTRAR OF VITAL STATISTICS `sp ® Fax(631)765-6145 MARRIAGE OFFICER � aQt' Telephone(631)765-1800 RECORDS MANAGEMENT OFFICER www.southoldtownny.gov FREEDOM OF INFORMATION OFFICER OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD PARKING PERMIT DATE: October 3, 2016 October 4, 2016 TIME: 8:00 AM — 6:00 PM LOCATION: Beach at end of Rocky Point Road, East Marion e Filming/Still Photography Place this Permit on the Dashboard, Passenger side of Vehicle Issue Date: September 15, 2016 Beach Parking fee - $10 per vehicle, per day between May 1 and September 30. ISSUED PERMIT Countersign application locations (s date(s), and time(s) Issue permit with name of applicant, ( ), ( ) 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. TOWN CLERK'S CHECKLIST FOR FILMING PERMIT NOTE: All payments must be cash or certified check Applicant: �Y-%8yea- Date Received: P �� ✓ 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$1,000,000 (one million dollars)per occurrence for the duration of the filming or still photography. Indemnification agreement stating the applicant agrees to assume all liability for and will indemnify and hold the town harmless of and free from any and all damages that occur to persons or property by reason of / said filming or still photography. Forward completed application to Chief of Police for approval or disapproval determination if Traffic Control Fee is required Approved Disapproved No Fee Required Fee in the amount of$ required ` - Forward certificate of insurance and indemnification agreement to Town Attorney for roval ✓ Approved Disapproved COLLECT FEES AS FOLLOWS: \p� Permit Fees (Prior to issuance of permit): Wo ✓ Film Fee - $100 per day of each day covered by the permit ��-g� ✓ Cleanup deposit: Separate certified check for$250 for each day covered by the permit. 6600 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. ov�� 7 �osu�fOL'��o ELIZABETH A.NEVILLE,MMC pyo Gy Town Hall,53095 Main Road TOWN CLERK P.O.Box 1179 C* Z Southold,New York 11971 REGISTRAR OF VITAL STATISTICS & ® Fax(631)765-6145 MARRIAGE OFFICER RECORDS MANAGEMENT OFFICER Telephone(631)765-1800 FREEDOM OF INFORMATION OFFICER ` www.southoldtownny.gov OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD To: Chief Flatley, Southold Town Police William Duffy, Southold Town Attorney From: Lynda M. Rudder, Deputy Town Clerk Dated: September 13, 2016 Re: Filming Permit Transmitted herewith is the application of Andrea Hetherington for a Catalog shoot permit to take place at Soundview Dunes Park, Southold and Rocky Point Beach, East Marion on Monday, October 3, 2016 and Tuesday, October 4, 2016 from 8am to 6pm. In accordance with Section 139.0 of the Town Code, please review the application and advice of approval or disapproval of the application and whether a traffic control fee is required,and the amount needed. APPLICATION FOR FILIVIING/SWILL PHOTOGRAPHY�+� PERMIT NO: V 45 Please Print or Type APPLICATION DATE: Cf' Is• NAME OF APPLICANT:&U og'�:es dr--fo�,It'jC&TON MAILING ADDRESS: (q3 C_LIN7yn/ NF_ a4c- r 2B , L)RaiCLyNN`/ zao's- PHONE: BUSINESS: HOME: 6[=(;:, NAME OF ORGANIZATION/COMPANY: -r CyS Ly Qoe-rS MAILING ADDRESS: ./173 GL JN GN A'l Aa: 2 "OKI L YnI, l 2 6_S PHONE: q? j. Z 9S . 0//7-- FAX: DESCRIBE TYPE OF ACTIVITY(e.g. Motion Picture,Commercial,Television. Catalog,Magazine, etc.): r-ATAL-O& Stpa-1 ®N 66-fscN &' AEaIC- & am&A Ano M6 LZ DATE(S)AND TIMES) OF PROPOSED FILMING/PHOTOGRAPHY: AA0A1 OC-1 36D -r -Tt&RSaq'1 Cka' 4-7-9, 20/6 S ens - 6,9r PROPOSED LOCATIONS) OF FILMING/PHOTOGRAPHY: (attach additional sheet, if necessary) C. rm Zc3- ea NAME OF PERSON IN CHARGE AT SITE: ANla A / r f- N&1 I OnI NUMBER OF PERSONS AT LOCATION(cast& crew included): /2- -t- 2 M cor--LS NUMBER AND TYPE OF VECHILES AT LOCATION: 2— TYPE OF SPECIAL EQUIPMENT: ND A) A AN M-C L D (A.6A RRA ANY SPECIAL REQUIREMENTS: A/0 Signature Return to: Southold Town Clerk Southold Town Hall 53095 Main Road P.O.Box 1179 Southold,NY 11971 7 ® DATE(MM/DD/YYYY) ACC)R o CERTIFICATE OF LIABILITY INSURANCE 12/08/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: CLAIRE PHONE 631 841 0270 ac No,631 841 0509 Eaton Insurance Agency aJc No Ext 120 Broadway ADDE-MRESS: calvino@eatoninsurance.com Amityville, NY 11701 INSURER(S)AFFORDING COVERAGE NAIC# INSURERA: HISCOX INS CO INSURED INSURER B. HARTFORD INS CO THE LOVELY WORKS LLC INSURERC: 193 CLINTON AVE,APT 2B INSURER D: INSURER E: BROOKLYN NY 11205 INSURER F. COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT 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 LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LTR D WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY Y USUEN2716127 12/7/15 12/7/16 EACH OCCURRENCE $ 1000000 CLAIMS-MADE 1 X7 OCCUR PREMISES Ea occur ante $ 1000000 MED EXP(Any one person) $ 10000 X 3rd party property damage PERSONAL&ADV INJURY $ 1000000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2000000 )ECT LOC PRODUCTS-COMP/OP AGG $ 2000000 POLICY❑ OTHER $ A AUTOMOBILE LIABILITY Y USUEN2716127 12/7/15 12/7/16 EeaBINd DtSINGLELIMIT $ 1000000 ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ X HIRED AUTOSX AUTOS Per accident A X UMBRELLA LIAB OCCUR Y UEUEN2716127 12/7/15 12/7/16 EACH OCCURRENCE $ 1000000 EXCESS LIAB CLAIMS-MADE AGGREGATE $ 1000000 DED I I RETENTION$ $ B WORKERS COMPENSATION 12WECI0138 12/7/15 12/7/16 XIPER STATUTE ETH AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N EL EACH ACCIDENT $ 1000000 OFFICER/MEMBEREXCLUDED? N/A (Mandatory in NH) EL DISEASE-EA EMPLOYE $ 1000000 If yes,describe under 1000000 DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $ A props,sets,wardrobe Y USUEN2716127 12/7/15 12/7/16 500,000 2000 DED equipment 1000000 2500 DED DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space is required) CERTIFICATE HOLDER CANCELLATION Town of Southold SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 095 Main Road THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 53 53 Box 1 in ACCORDANCE WITH THE POLICY PROVISIONS. Southold, NY 11971 AUTHORIZED REPRESENTATIVE ©1988-2013 ACORD CORPORATION. All rights reserved. ACORD 25(2013/04) The ACORD name and logo are registered marks of ACORD 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. Sign t Date Printed name Ow W Title Rudder, Lynda From: Flatley, Martin Sent: Tuesday, September 13, 2016 4:29 PM To: Rudder, Lynda Subject: RE:film#2 1 have no objection to this photo shoot taking place.Thee does not appear to be any need of a police presence, however,their vehicles should use a parking placard for the end of Rocky Point Road. Martin Flatley, Chief of Police Southold Town Police Department 41405 State Route 25 Peconic, New York 11958 631-765-3115 -----Original Message----- From: Rudder, Lynda Sent:Tuesday,September 13, 2016 3:34 PM To: Duffy, Bill <billd@southoldtownny.gov>; Silleck, Mary<marvs@southoldtownny.gov>; Flatley, Martin <mflatlev@town.southold.ny.us>; Blasko, Regina <rblasko@town.southold.ny.us> Subject: film#2 Your message is ready to be sent with the following file or link attachments: film 2_20160913142518.pdf Note:To protect against computer viruses, e-mail programs may prevent sending or receiving certain types of file attachments. Check your e-mail security settings to determine how attachments are handled. 1 Rudder, Lynda From: Duffy, Bill Sent: Wednesday, September 14, 2016 8:24 AM To: Rudder, Lynda; Silleck, Mary; Flatley, Martin; Blasko, Regina Subject: RE:film#2 No objection to the permit -----Original Message----- From: Rudder, Lynda Sent:Tuesday,September 13, 2016 3:34 PM To: Duffy, Bill; Silleck, Mary; Flatley, Martin; Blasko, Regina Subject: film #2 Your message is ready to be sent with the following file or link attachments: film 2_20160913142518.pdf Note:To protect against computer viruses, e-mail programs may prevent sending or receiving certain types of file attachments. Check your e-mail security settings to determine how attachments are handled. 1 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. 13 � Sign a Date Printed name J Title APPLICATION FOR FILMING/STILL PHOTOGRAPHY PERMIT NO: Please Print or Type APPLICATION DATE: Ct' IS- /6 NAME OF APPLICANT: & Qaes MAILING ADDRESS: N3 C L-w w &JF_naAr r A-pr2B , -6p- &yly NY II c6 PHONE: BUSINESS: G �G 33q ( %6 9 HOME: 6(f4 3 R �=476!7< NAME OF ORGANIZATION/COMPANY: 7 H e t oyr- L�j (A)0 e.,-.S MAILING ADDRESS: /013 CL JN I ON A s P. Aa: Z P Alpe L M) PHONE: 7 g. Z 9S • Q :�- FAX: DESCRIBE TYPE OF ACTIVITY(e.g. Motion Picture, Commercial, Television. Catalog,Magazine, etc.): DATE(S)AND TIME(S) OF PROPOSED FILMING/PHOTOGRAPHY: MON ori' .3P-D -r -TmZatq-1 Oc r 4-TV, Zol6 S ang - 6,OM PROPOSED LOCATION(S) OF FILMING/PHOTOGRAPHY: (attach additional sheet, if necessary) NAME OF PERSON IN CHARGE AT SITE: ND _ T - Nl.%i—to A/ NUMBER OF PERSONS AT LOCATION(cast& crew included): /Z --J-- 2 MWL-(S NUMBER AND TYPE OF VECHILES AT LOCATION: 2— ,5tA VS TYPE OF SPECIAL EQUIPMENT: ALDA) A Anl/�lLI-C L f.AA FL- A- ANY SPECIAL REQUIREMENTS: fl/O Signature Return to: Southold Town Clerk Southold Town Hall t 53095 Main Road P.O. Box 1179 Southold,NY 11971 Ilt 10 4� 1,0 Il . � . ......N ' �dASE� , ',lPMqr§5'nVChaisd;BanK wv-o am VV!0 '.S" e ue� Iv T:y 1'. • �1-t"09/14/201,6' '.7�Beooklyh;,NY,11, 05 K-V V T f 0 il�, a Y V, "0 7., F io ,Ila N , — �,, I, - "' �T-H t h'Cldrk;.,I�,�;i��,'l�,t�l,,,����C, ......... ..r;1' Iq "v n% -V'-Eig ht'hu nd rod',Ahd700/1 00 It Ig Ae. :6bL W;i A,Avt.f tl,1 1. % %4 -t- ill , ,cn f, ,, -, buthlb if,'�Tb , 6",016'ek: "b"'4" L � " ",114 tl,f +11 j-" - A Yck ���lt,11,40`��,,,`;A I 1'� it"i"'It R.W"t ThEt' works LLG Q 11297t, j=, If Vill el,, AUTHORIZED SIGNATUR 003q,'A`bfloV',T "�W r5 11'000 20011' 1:0 2 100002 li: 7 7 9 68 2 20 711''