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g UIL, MG DEPART ENT
1146 Route 28, South 'Yarmouth, Mtn 02664 508 398 22_ eft, 1240—
MAR 16 2023
APPLICATION FOR CERTIFICATE OF INSPECTION Q---.-- J
BUILDING DEPAR l MEN1
March 1, 2023 PAYABLE UPON RECEIPT _
(X) Fee Required$445.00
( ) No Fee Required
In accordance with the provisions of the Massachusetts State Building Code, Section 110.7, I hereby apply for a
Certificate of Inspection for the below-named premises located at the following address:
Street and Number: )' O- s�� Le,i('L
Name of Premises: QV vtrr Stz."1 Q250 r- Tel: S-0$`2 3- fl 3
Purpose for which permit is used: to e'F c4 I< oP t hS Pe c,4,o-, for It C evu
License(s) or Permit(s)required for the premises by other governmental agencies:
License or Permit Agency
Certificate to be issued to N� ,��. aL Rev Tel: S-09-- `f 143-' - 3
Address: `3'V 5o" ' SL s,,
e r kjt
Owner of Record of Building VT Qts 12esar�
Address 30) st„v,
Pre ent Holder of Certificate
Si ature of person to whom Titl
Certificate is issued or his agent -h')=3
Date
Email.Address: 4hwvnarc' L er lcsaj- '\
Instructions: Make check payable to: Town of Yarmouth
1146 Route 28, South Yarmouth, MA 02664
Return this application to: Building Inspector's Office
Please note: Application form with accompanying fee must be submitted for each building or structure or part
thereof to be certified. Application must be received before the certificate will be issued. The building official shall
be notified within ten(10) days of any change in the above information.
PLEASE SEND US A COPY OF YOUR WORKER'S COMPENSATION INSURANCE FORM WITH THIS
APPLICATION OR WE CANNOT ISSUE YOUR CERTIFICATE OF INSPECTION.
Certificate of Inspection# QO.V7_2 j_ 0 U 6-776/4,to
04/01/2023-04/01/2024
AcoRD® CERTIFICATE OF LIABILITY INSURANCE DATE(z02 ')
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 have ADDITIONAL INSURED provisions or 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
Marsh USA,Inc. NAME
1166 Avenue of the Americas PHONE FAX
New York,NY 10036 E-MAIL
ADDRESS
INSURER(S)AFFORDING COVERAGE NAIC#
CN133703919-GL--22-23 INSURER A:Everest Premier Insurance Company 16045
INSURED INSURERB:Everest Denali Insurance Company16044
EOS Investors,LLC _ -_
444 Madison Avenue,Floor 14 INSURER C:NIA N/A
New York,NY 10022 INSURER D:Everest National Insurance Co
INSURER E:
INSURER F
COVERAGES CERTIFICATE NUMBER: NYC-011552062-01 REVISION NUMBER: 0
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 1 POLICY EXP
LTR INSD VWD POLICY NUMBER (MMIDD/YYYY)i(MMfDp/YYYY) LIMITS
A X 1 COMMERCIAL GENERAL LIABILITY CCIGL00029-221 09/12/2022 09/12/2023 EACH OCCURRENCE $ 2,000,000
0- MAGETORENTED CLAIMS-MADE X OCCUR PREMISES 1,000,000
(Ea occurrence) $
MED EXP(Any one person) $ _
PERSONAL&ADV INJURY $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000
POLICY[ I JECT X LOC PRODUCTS-COMP/OP AGG $ 2,000,000
OTHER: 1 $
B AUTOMOBILE LIABILITY CC1CA00027-221 (AOS) 09/12/2022 '09/12/2023 COMBINEDSINGLE LIMIT $ 2,000,000
(Ea accident)
D
X ANY AUTO CC1 CA00056-221(MA) 09/12/2022 09/12/2023 BODILY INJURY(Per person) $
OWNED SCHEDULED BODILY INJURY(Per accident $
AUTOS ONLY AUTOS )
HIRED NON-OWNED PROPERTY DAMAGE
AUTOS ONLY AUTOS ONLY (Per accident) $
X Garage Keepers Garage Keepers $ 1,000,000
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE $
1 DED RETENTION$ $
A V ORKERSCOMPENSATION ' CC5WC00075-231 01/01/2023 01/01/2024 Io—T
• AND EMPLOYERS'LIABILITY Y/N Xj PER STATUTE_ _LRH-
___
ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000
OFFICER/MEMBEREXCLUDED? N N/A
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space Is required)
CERTIFICATE HOLDER CANCELLATION
12.1 Resorts Riviera Beach Resort Owner, SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
LLC THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
EOS Investors LLC ACCORDANCE 1MTH THE POLICY PROVISIONS.
444 Madison Ave
New York,NY 10022
AUTHORIZED REPRESENTATIVE
I :yzsand 4 14Sr41 Tote.
0 1 988-201 6ACORD CORPORATION. All rights reserved.
ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD