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,•_ �- -�r BUILDING DEPART
�MATFAG ES[ 3 1146 Route 28, South Yarmouth, MA �+
C E I V E
APPLICATION FOR CERTIFICATE OF INSPECTION MAR 1 6 2023
March 1, 2023 PAYABLE UPON "COWL DEPARI nnFNT
(X) Fee Re. . - o,:-=_ -----
( )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: Jr rV
Name of Premises: -_��� J.‹ ,,r `��s�"- ��`"' �-��� � 1� ,�� ���,�Tel: '� k
Purpose for which permit is used: ,�,tx.t... i;„SRt,4-,a A c 1 WA SA. 401
License(s) or Permit(s)required for the premises by other governmental agencies:
License or Permit Agency
3Vi W k 0.
Certificate to be issued to ``.4, l:.J C Y v'1 Tel:
Address: '}c11 Sow `11o,rc. c. 5 b( tf166
Owner of Record of Building ���,�1g ��,,.� (,�o%}t,r (2esbA-- of ���r LL.C-
Address � �a�1'� op-
Pre•-nt Holder of Certificate
45
Ain
t� erf: 'son to whom Title
Ce ificate is issued or his agent (3--1 r-`)3
Date °1(A'ir CA\in
Cal
Email Address: r\_r S rt Nat 1Q✓�S h h
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# 661 CI—ate O. �?
04/15/2023 —04/15/2024
A�® CERTIFICATE OF LIABILITY INSURANCE D02/02/2023
�
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(les)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 FAX
1166 Avenue of the Americas �l+/C No.Ext2 (A/C,No):
New York,NY 10036 ADDRESS
INSURER(S)AFFORDING COVERAGE NAIC#
•CN133703919-GL--22-23 INSURER A:Everest Premier Insurance Company 16045
INSURED INSURER B_Everest Denali Insurance Company _ 16044
EOS Investors,LLC
444 Madison Avenue,Floor 14 INSURER C:NIA NIA
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.
INSREFF 1 POLICY EXP
TYPE OF INSURANCE INSD ND POLICY NUMBER (MM/M/D�D/YYYY)[(M IDD/YYYY) LIMITS •
A X COMMERCIAL GENERALLIABILnY CC1GL00029-221 09/12/2022 09/12/2023 EACH OCCURRENCE $ 2,000,000
CLAIMS-MADE 1 X OCCUR REM 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 PRO- x LOC PRODUCTS-COMP/OP AGG $ 2,000,000
JECT
OTHER:
B AUTOMOBILE LIABILITY CC1CA00027-221 (AOS) 09/12/2022 09/12/2023 COa BII EDSINGLE LIMIT $ 2,000,000
nt)
D X ANY AUTO CC1CA00056-221(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 $
DED RETENTION$ $
A WORKERS COMPENSATION CC5WC00075-231 01/01/2023 01/01/2024 XI STATUTE_ _ER
AND EMPLOYERS LIABILITY Y/N 1,000,000
ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $
OFFICER/MEMBER EXCLUDED? N N/A 1,000,000
(Mandatory in Nth E.L.DISEASE-EA EMPLOYEE $H
If yes,describe under ISEASE-POLICY LIMIT $ 1,000,000
DESCRIPTION OF OPERATIONS below E.L..
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 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
do EOS Investors LLC THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
444 Madison Ave ACCORDANCE WTH THE POLICY PROVISIONS.
New York„NY 10022
AUTHORIZED REPRESENTATIVE
i�Jt 44 W.S.14 'Fte.
01988-2016 ACORD CORPORATION. All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
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