HomeMy WebLinkAboutCI-23-005168-05 0
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r :. RECEIVED
n•�. v �. TOWNOF A
Icy MAR 16 2023
vo .1. ry,1 BUILDING DEPARTMENT
j 41
� ;" � `' ' 1146 Route 28,South Yarmouth,MA 02664 508-398-2231 eijil-t260 UEPARTrv1ENT
APPLICATION FOR CERTIFICATE OF INSPECTION
March 1,2023 PAYABLE UPON RECEIPT
(X) Fee Required$550.00
( ) 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: -' (3 ( ffit% a k...M; U„\VO , 14.,(rvy t
� L y
Name of Premises: lilt, 1 t D 1 * h Tel: ' 1`- 1
Purpose for which permit is used: '�'t <� `
License(s)or Permit(s)required for the premises by other golernmental agencies:
License or Permit Agency
Certificate to�Af�e issued to a`(t V d5e«l f 2 °�
Address: D S(�U Tel: � � .1
Owner of Record of Building ( Cal SkC.1).t. hi
Address 2 3 S, 51,o,-c a--. >_ ys+-+ro-.N rd1A 0-6 4`I
Present Holder of Certificate cJ. A..ar. 1- ✓" 0... l
,
•
ig re o person to whom 6Me l driff t 9,
C Title
ficate is issued or his agent ` o( 262,3
1} Date
Email Address: k kl.olty kILYl(3r. "� Cw.
S 1 oo/t6 ,(tiny},
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# Lh-7_i6
04/01/2023-04/01/2024 D S�(o b
,4co OR CERTIFICATEOF DATE(MMIDD/YYYY)
r`,.,� LIABILITY INSURANCE 02/02/2023
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. NAIv1EE
1166 Avenue of the Americas PHCN (FAX
A/C
New York,NY 10036 C.,No.EMAIL
Eat): A�No):
ADDRESS:
INSURER(S)AFFORDING COVERAGE NAIC#
CN133703919-GL--22-23 INSURER A:Everest Premier Insurance Company 16045
INSURED
EOS Investors,LLC INSURER B:Everest Denali Insurance Company 16044
444 Madison Avenue,Floor 14 INSURER C:NIA N/A
New York,NY 10022
INSURERD:Everest National Insurance Co
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: NYC-011552063-01 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 ADDL SUBR
LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER POLICYIDDEFF I POLICY EXP
(AAAAIDD/YYYYI i(MMIDD/YYYY) LIMITS
A X COMMERCIAL GENERAL LIABILITY CC1GL00029-221 09/12/2022 09/12/2023 EACH OCCURRENCE $ 2,000,000
CLAIMS-MADE X OCCUR DAMAGE TO RENTED
PREMISES(Ea occurrence) $ 1,000,000
MED EXP(Any one person) $
PERSONAL&ADV INJURY $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000
POLICY jE T X LOC
PRODUCTS-COMP/OP AGG $ 2,000,000
OTHER:
B AUTOMOBILE LIABILITY CC1CA00027-221 (AOS) 09/12/2022 09/12/2023 COMBINED SINGLE LIMIT
I) (Ea accident) $ 2,000,000
X ANY AUTO CC1 CA00056-221(MA) 09/12/2022 09/12/2023 BODILY INJURY(Per person) $
OWNED SCHEDULED
AUTOS ONLY AUTOS BODILY INJURY(Per accident) $
HIRED NON-OWNED
AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE $
X Garage Keepers (Per accident)
Garage Keepers $ 1,000,000
UMBRELLA LIAB OCCUR
EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE
AGGREGATE $
DED RETENTION$
A VWRKERSCOMPENSATION CC5WC00075-231 01/01/2023 01/01/2024 X MUTE OTH
ER] - $
AND EMPLOYERS'LIABILITY YIN
ANYPROPRIETOR/PARTNER/EXECUTIVE — -— - --- ------ -
OFFICER/M EMBER EXCLUDED? N N/A E.L.EACH ACCIDENT $ 1,000,000
(Mandatory in NH)
If yes,describe under E.L.DISEASE-EA EMPLOYEE $ 1,000,000
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
RJ Resorts Red Jacket Beach Resort
Ownesorts SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
EOS Investors LLC THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
444 Madison Ave ACCORDANCE WITH THE HE POLICY PROVISIONS,
New York,NY 10022
AUTHORIZED REPRESENTATIVE
W2a)7424 ASS TTsc.
88-2016 ACORD 25(2016/03) The ACORD name and logo are registered marks oACORD CORPORATION. All rights reserved.
ACORD
s' 'MICA
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