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MIIOii C
y�{ BUILDING DEPARTMENT
1 146 Route 28, South Yarmouth, MA 02664 508-398-
. V E D
APPLICATION FOR CERTIFICATE OF INSPECTION MR 16 23
March 1, 2023 PAYABLE UPON G DE PA It TM ENT
(X) Fee Req 4411-4 760— —
( )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: Q,q1 ;,•�`
Name of Premises: �, / Qtr\- Tel: S-09- 3ci 8-2`)8
Purpose for which permit is used: kxNSf 4-1,n 1`tuSt_
License(s) or Permit(s) required for the premises by other governmental agencies:
License or Permit Agency
Certificate AD be issued t � ba}tr- et)eIA- Tel: S-68-
Address: CkA. Saw . S1/1orc. Vr j&
Owner of Record of Buil ing S g.e.16;i 4? W u, U4 —' �t r� nj r
Address g-cl1 S 0,A Sta,,,� Dr;v�
Present Holder of Certificate
(3,61-te-•,
Sig ture o person to whom Title
Certificate is issued or his agent e -
Date
Email Address: k\ACkil&rrAl A^ e ft&)a ,-TtsL,.ly • (,o
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 #
04/15/2023 -04/15/2024
ACC)RL CERTIFICATE OF LIABILITY INSURANCE DATE VYYI^7
�� D2/02/2023
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).
COPRODUCMarsh USA,Inc. NA
MEACT
1166 Avenue of the Americas (N/C No Ex� FAX
No)
New York NY 10036 E-MAIL
ADDRESS
INSURER(S)AFFORDING COVERAGE NAIC#
CN133703919-GL--22-23 INSURERA:Everest Premier Insurance Company 16045
INSURED
EOS Investors,LLC INSURER B:Everest Denali Insurance Company 16044
444 Madison Avenue,Floor 14 INSURERC:N/A N/A
New York,NY 10022
INSURER D:Everest National Insurance Co
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: NYC-011551544-02 REVISION NUMBER: 6
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 NMVWD POLICY NUMBER IDPOLICYEFF POLICY
A X COMMERCIAL GENERAL (MMD/YYYY) (MMIDD/YYYY) LIMITS
LIABILITY CC1GL00029-221 09/12/2022 09/12/2023 EACH OCCURRENCE $ 2,000,000
—Di—WAGE TO RENE
CLAIMS-MADE X OCCUR PREMISES(Ea occur ence) $ 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
PRO- v
POLICY JECT X LOC
PRODUCTS-COMP/OP AGG $ 2,000,000
OTHER: $
B AUTOMOBILE LIABILITY CC1CA00027-221 (AOS) 09/12/2022 '091109/12/2023 COMBINED SINGLE LIMIT $ 2,000,000
D (Ea accident)
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 PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) $
X Garage Keepers Garage Keepers $ 1.000,000
UMBRELLALIAB OCCUR
EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE
AGGREGATE $
DED RETENTION$
A VVORKERSCOMPENSATION CC5WC00075-231 01/01/2023 01/01/2024 I SPTAERTUTE ER 1 I I OTH- $
X
AND EMPLOYERS LIABILITY Y/N
ANYPROPRIETOR/PARTNER/EXECUTIVE ---- - -
OFFICER/MEMBER EXCLUDED? N N/A EL 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 Blue Water Resort Owner,LLC
do EOS Investors LLC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
444 Madison Ave THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
New York„NY 10022 ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
I 7frea ia.4 22Sr f 47ctc.
ACORD 25(2016/03) The ACORD name and logo are registered marks Bof ACORD
CORPORATION. All rights reserved.