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' Thomas F.Geiler,Director V Building Division 0 9/2- f s� Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 Office: 508-862-4038 www.town.barnstable.ma us Fax: 508-790-6230 EXPRESS PERIVRT APPUCATION - RESLDEl`TTIAL O1V]L� Not Valid withoul Red X-Press Imprint Map/parcel Number Property Address � � � a EXesidential value of Work JU Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address Contractor's Name /( U Telephone Number 5o g—q A V- Q Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) ZWorkman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am,the Homeowner I have Worker's Compensation Insurance Insurance Company Name Workman's Comp,Policy# C( Copy of Insurance Compliance Certificate must be on file, Permit Request(check box) Re-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows. U-value ---__(maximum.44) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc *iR19: ote: ro Owne ust sip gn caner Letter of Permission. ense is required. SIGNA Q:Forms:expnmg Revise071405 4 Board ®f.B uilding One Ashb Re l ®�� d�,qtq,�Standards ®� Place m .R®®n. 1301 Home Boston' Massachu.sett 'Pr®veient--,Co a ��1®� °a�t®r Registration SER cONSl�RUCT Registration: 11263, DEANFRA FRAsER d®N CO. Time: DSA BA P-0- BOX 1645 �doiration: 3/23/20Os io/1 C®TLJdI' {�q Tr# 127s2o A 02635 DP9-CA7 gy SOM-05/08-PC8490 _ . Update Address ❑ Address and return a ard.Af r&real®n for 1$oard of Bulldim - --- - ❑ ewral ❑ Ei-Pl®3 went change. g Regulattoas and Standards ❑ ]Lost Card "ONE 1'W'-'WVEANEN-r COiyTRACTOR � license or re Registration:312536 before the l�ta anon v JudMdul dal for �iration: 3/2' pg Board Of l� d� use ly atpir iOn date. Yf found return to- '®� Tie; •p TnV 127920 One Aspabtaa ton Plae Pkegnlati®ns and �d�8 FRASER CONSTRU ® ®n,1va.O2101i 'm 1301 DEAN FRASER C710iy 0O.y .ja 4558 RT 28 COTUI T.MA 02635 AdmWstrnt., I�®tnffd without si gnatare • w ...... .....:._._.� :. ..•.. .. ...............::::.................�................:.:. 1-3 ??; PRODUCER A MATTER OF I TION WISE & QUINN INS AGCY ONLY ANO 'CONFERS NO RIGHTS UPON THE CERTIFICATEOR,449 PLEASANT ST HOL®ER. THIS CERTIFICATE DOES NOT AMEN®, EXTEND O , ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. BROCKTON MA 02301 COMPANIES AFFORDING COVERAGE 24WCB COMPANY INSURED HARTFORD UNDERWRITERS INSURANCE COMPANY COMPANY FRASER CONSTRUCTION CO PO BOX 1845 COTUIT MA 02635 COMPANY A C COMPANY THIS :.::::::::::::::._.;:.;:?:.,}?>:.:?::;::>:z:>:::>}:::^::«':>:::<:.....: :::::>::>.<':::;:::>::::::>:;::'>i«:<:>':>:::i:>:::< ':> :>z:::'::<:::z:::::::s:?::>`:>'::i:::>:<:?:s3:z:::z:3»:<:::::::>::»«::r::>:>::>::::>:::>::>:<::::z:>:.?>:.:.};:?.;•.}'::::::: IS TO CERTIFY THAT THE � ••� .... . ....... "-OF INSURANCE LISTED BELOW•HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE P INDICATED, NOTWITHSTANDING ANY REQUIREMENT OLICY PERIOD , 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. CO LTR TYPE OF INSURANCE POLICY NUMBER• POLICY EFFECTIVE POLICY EXPIRATION DATE(MM\DD\YY) DATE(MM\DD\YY) LIMITS GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY ' GENERAL AGGREGATE $ PROD ACTS-C O MP/OP CLAIMS _ AGG. MADE OCC UR. - OWNER'S&CONTRACTOR'S PROT. PERSONAL&ADV.INJURY $ EACH OCCURRENCE $ FIRE DAMAGE(Any one fire) $. - AUTOMOBILE LIABILITY MED.EXPENSE(Any one person) $ ANY AUTO COMBINED SINGLE ALL OWNED AUTOS LIMIT. $ SCHEDULED AUTOS s BODILY INJURY (Per Person) $ HIRED AUTOS � , NON-OWNED AUTOS BODILY INJURY (PerAccldent) $ GARAGE LIABILITY DAMAGE • _ ... ANY AUTO < AUTO ONLY-EA ACCIDENT $ ' OTHER THAN AUTO ONLY: EACH ACCIDENT $ EXCESS LIABILITY AGGREGATE $ UMBRELLA FORM EACH OCCURRENCE $, OTHER THAN UMBRELLA FORM AGGREGATE_ $ A WORKER'S COMPENSATION AND, _ EMPLOYER'S LIABILITY (UB-794X619-1-06) LIMITS " {`? 09-26-06 09-26-07 STATUTORY THE PROPRIETOR/ EACH ACCIDENT $ PARTNERS/EXECUTIVE X INCL OFFICERS ARE: EXCL _ DISEASE—POLICY LIMIT $ OTHER DISEASE—EACH EMPLOYEE $ 500 000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/RESTRICTIONS/SPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO':�::�`::":;�-?-.-:�::::r?}?:•}s:,A�:•:'::i:?:?R••:}.�::.l....:::.•:::.::::::::::::?:;.:?.<•::::.:,-:...�.:.::::..-::::.::.,:.::•..:,:....:..{.::.,.:,..,..�.:�?:�:..,•?.�..,.-}:THE '{C.:.E.v.RT...I.FI..C:,.A..T:..:E::.:H..,O...LDER AFFECTING WORKERS .CO :,•::::,.},... • �?�{:::,:�:^:.}..:,,�V' �y�(y�y�( �,,y� MP COVERAGE. :........v n......::::::.::::}•:::::::::n:v:.::........• •F?v.{'F.4:.fi:•}}i:.:::::.v:v:.v... }\.y?i'{. :. :.A,..':.' �"$ .. ..p{� -?v:$:::.v..:.:v.:...v:...v::vii•?:�v::::.::•.v:.v.............. ...............v:?:-::{?titi{F,.::>fi.::�: v:.v:.:vf`.;:.v::::fYs:•?:•?:i-:.:v-{:vn•v:::: �(g,��j' f��.;•?::::::::::.::.v:::::::,.::::::::.{:::.::::�nvr:'.}::::.:v:::::.??'._:::::._:................ u :.:::u:.v:x:.v:•:•k^}}::�{ x:.vv:?w:::::.v}}{{:vv: 'FIT�9�..^.!��P.�[' �{.;:;f...... v v::F':{?.?nviY....}_...::r:v:.;.v-v�•::n}.n?'...rrr{h}-:'.{?:-?:v::v:?::::'?}:?}:.. , n.:..................u.- .. ..n.v..........n}?}$i'iii:i$S:}.{{}:{x".}:'{?_':'•y n{% .•<•ii'�i'�Yi•`.{'}:f�ii'r}i`:•ry:l•:?<}l':{i:i. SPIOULD A{NY OF THE ABOVE DESCRIBED POLICIES BE CApICELLEDI BEFORE EXPIRATION DATE THEI)EOF, THE ISSUING COpIPA111V WILL FRASER CONSTRUCTION ERDEAVOR TO MAIL '' I PO BOX 1845 ' 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER RAINED TO THE LEFT, BUT FA1L116IE TO MAIL SUCH NOTICE SHALL IMPOSE No OBLIGATION OR CO TU 2 T MA-02635 LIABILITY OF ANY KIND UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ......r.�v.v:.v:L}?}Y::}:•}i:�:}}:}:{??-??:{��v?%:wn:v}�-}?i}-ryv::•:.v::::.v:......::x:::.v:......n•vv.v::....:nv.v:nv:::v.:..::::::::::::...:.::::::::.......: .. .............. �/////�/��/J����^� .............:::?::::::.v:::::?{-isb}•.?-..:::::^?}$}Y•}:?:•v,{•?Y?•?:?{::}::.:.-:::?{�:{??•.'•?:?{{!{:i:•}{?.??}:{4}:{:.:?.:isi�?}?:6:{.-.:..yr:'<nii??}?}??::�•:: .:: :.v::...-..:.....n:��!a'-%•%[:•:•}}:-::.}'..fw�:::........... The Commonwealth of Massachusetts Department of Industrial Accidents VIF Off ice of Investigations 600 Washington Street Boston, MA 02111 s� wwra.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): T (a,QU,y Address: p CD fj 0-V j gt{� — - City/State/Zip: �)tla� 9 v CL- o 9,635 Phone #: Eo g--qA q~ a gq g_ Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with�—� 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 1 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.JKRoof repairs insurance required.]t employees. [No workers' 13.❑Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'.compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: 7 1 '7 X 6 l -L Expiration Date: C/ 96 Job Site Address: 6-5 Ma'OL a­,(� City/State/Zip: � Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereif u er t s sand er o per ry that the information provided above is true and correct. IE� Si ature: Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2. Building(Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: ,. z007 11:24 6174845862 HAMMOND PAGE 03/03 Sep. 7. 2007 5:49PM No, 4545 P. 3 TOTAL INVESTMENT.- LANDMARK/WOODSCApE AR 30.- $9,ajig5 *4 Star Warranty Upgrade will be.applied if proposal is signed and returned within 10 days. (see enclosed brochure) 2% discount if paid by check Payable immediately upon completion NO MONEY')OWN-NO Payment at the start or part way thru PaYments accepted are, CASH-CHECK- MASTERCARD-VISA- AMERICAN EXPRESS a Any payments not rnade within 30 days of completion will be charged 18%for every 30 days the payment is late, Possible Ektra-After the shingles are :removed from the roof, we will lift one sheet of Plywood to matte sure that the insulation is not up against the Plywood Preventing ventilation from the eaves to the ridge, If it is, ventilation Panels will, be installed by; removing the plywood sheathing, installing the panels, the plywood over and, theca re-installing the plywood. If needed, this would be charged for as an extra at the rate of$4.00 per panel including Materials N Labor. There are 6 Panels per sheet of plywood. Possible Extra-Any rotted or otherwise deteriorated trim boards, plywood sheathing, lead flashing, or other carpentry needing replacement will be done and charged for as an extra at the rate of$50.00 per hour, plus materials, plus 20% overhead mark-up on total extras. FRASER CONSMUCTION Warranties the labor for 12 years FRASER CONSTRUCTION Warranties the shingles against Blow-Offs for 10 years. CERTArMED Warranties the shingles and labor 100% through the Sure Start Warranty duration. CERTAINTEED Warranties the shingles to be ALGAE resistant for the duration of the Sure Start Warranty depending on the shingle that was purchased. Any deviation or alteration from above speeifacation will be executed upon written orders axed will become an extra charge over an above the estimate. All agreements contingent upon strikes, accidents or delays are beyond our control, Owner should carry fire, tornado and other necessary insurance upon the above work. We, if not accepted within thirty days may withdraw this proposal. FRASER CONSTRUCTION: Carnes Workman's Compensation and Public Lfiabilit Insurance on the above work, certiScate available upon request. y DATE OF ACCEPTANCE: Q I . HdmeOvvner Fars .:. Q �truction Town of Barnstable *Permit# 2L Gv Expire onths from issue date Regulatory Services Fee �o�oyy.ye s F.Geiler,Director ' 5 ' Building Division '9 2N77n Perry,CBO, Building Commissioner '��� . Street,Hyannis,MA 02601 oyVN OF g ,aNSY ww .town.barnstable.ma.us T Fax: 508-790-6230 Office: 508-862-4038 EXPRESS PERAUT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Number 6�0 ` Map/parcel _ -3 Z Property Address U 45 /,' 9EL Residential Value of Work W• Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address 7 t Contractor's Name_ U g M L Telephone Number ���--7V 7 j �3Home Improvement Contractor License#(if applicable) v Cons coon Supervisor's License#(if applicable) / �[ Workman's Compensation Insurance Check one: ❑ Im a sole proprietor Vthea Homeowner I have Worker's Compensation Insurance Insurance Company Name �Wj l�V am Workman's Comp.Policy# Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) Re-side Replacement Windows/�doorss//s�lideers. U-Value (maximum.44) Where required: Issuance of this does-o aTn? P lance wit er town deparhnent regulations,i.e.Historic,Conservation,etc. ***Note: Pr perry Owner must sign Property Owner Letter of Permission. opy of the Home Improvement Contractors License is required. SIGNATURE: Q:ForMs:expmtrg Revise061306 a l o y_o y G o V Go N Z F l {Lo C la 3 `}N C6, co o yt� Y ca Z J m 1Y- 1 j7Z W,1� ;1 The Commonwealth of Massachusetts Department of Industrial Accidents i _ Office of Investigations ' n ra ' 600 Washington Street Boston,MA 02111 5� www.mass.gov/dia Workers' Compensation Insurance.Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): . TQVd71A5 Mu L L-C-1) Address: ?,0 1'80� P`Z City/State/Zip:AWj2ST&V3 h Phone.#: F—7 37— 52,/ 9 Are u an employer? Check the appropriate box: Type of project(required):. 1. I am a employer 4. ❑ I am a general contractor and I with�— 6. ❑New construction . employees(full and/or part-time).* have hired the sub-contractors 2.El am a'sole proprietor or partner- listed on the-attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers' comp.insurance • comp. insurance. t' required.] 5. We are a corporation and its 10.❑Electrical repairs or additions officers have exercised their 11. n 3.❑ I am a homeowner doing all work i ❑Plumbing repairs or additions. P myself. [No workers' comp- right of exemption per MGL 12.❑R repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13. Other kL���',�. comp.insurance required.] . *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is.the policy and job site information. Insurance Company Name: I` 19 5 6 Policy#or Self-ins.Lic.#: a 1- 3- Expiration Date: // Z//,07 Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure.to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DLA for insurance coverage verification. I do hereby certify- er the pai an enalties of perjury that the information provided ab vvo 7�: a and correct Signafore: Date: �/. _ Phone#: 52&_ 3 Official use only. Do not write in this area,tb be completed by city or town ofciaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health.2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire, . express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee-of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the' dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to*operate a business or to construct buildings in the commonwealth for any applicant who has not produced.acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7 )states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract foz the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented'to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contiactor(s)name(s), address(es)and phone number(s) along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. "The affidavit should be returned to the city or town that the application for the'permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete'and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary) and under"Job Site Address"the applicant should write"all-locations in (city-or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related fo any business or commercial venture (i.e. a dog license or permit to bum leaves-etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone-and fax number:. The Commonwealth of Massachusetts Department of 1ndustriai Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 11-22-06 www.mass.gov{dia �oFIME _ 'Town of Barnstable. h Regulatory Semees w rB '$ Thomas F.Geller,Director 1619;. ]Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis,NIA 02601 w ww.town.b arnstable.maxs Office: 508-862-403 8 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using ABuilder I, ! -661 — AMAVIV/ ,as Owner of the subject property hereby authorize Dd Aj to act on my behalf, in!matters relative to.work authorized bythis building permit application for: . IVtC A-LIE (Address of Job) .7// ?10Z Signature of Owner Date N. Print Name 4 Q TORM S:OWNEnERM IS S ION GRAN fTE C' ATE INSURANCE COMPANY 70285-0000 •_ WC 885_5'9.33 1310 013-66-11o6-oo .••.•. PENNSYLVANIA DOUG Member Companies of LLEN PO BOXX 1274 274 MARSTOWS MILLS, MA 02648-0000 01M American International Group EXECUTIVE OFFICES: 70 PINE STREET, NEW YORK, N.Y. 10270 SEE NAME AND ADDRESS SCHEDULE - WC990610 OCEANSIDE INSURANCE AGENCY INC WORKERS COMPENSATION AND EMPLOYERS 52 WEST MAIN ST LIABILITY POLICY INFORMATION PAGE HYANN I S, MA 026o 1-00o0 INSURED IS PREVIOUS POLICY NUMBER INDIVIDUAL NEW OTHER WORKPLACES NOT SHOWN ABOVE:SEE NAME AND ADDRESS SCHEDULE - wc9go6lo ITEM 2 POLICY PERIOD 12:01 A.M.standard time at the Insured's mailing address FROM 1 1/2 1/06 TO 1 1/2 1/07 ITEM 3 A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers Liability Insurance: Part Two of the policy applies to the work in each state listed in item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 100,000 each accident Bodily Injury by Disease $ SOO.000 policy limit Bodily Injury by Disease $ 100,000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: SEE ENDORSEMENT - WC2003o6A ITEM 4 The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Estimated Total Rate Per Estimated Remuneration Premium Classifications Code Number mlunerat on Annual 3 Year N Annual 11 3 Year SEE EXTENSION OF INFORMATION PAGE - WC7754 TAXES/ASSESSMENTS/SURCHARGES $152 EXPENSE CONSTANT(EXCEPT WHERE APPLICABLE BY STATE) $284 MA MINIMUM PREMIUM $500 MA TOTAL ESTIMATED PREMIUM $3,926 If indicated below, interim adjustments of premium shall be made: 11 Semi-Annually 11 Quarterly Monthly DEPOSIT PREMIUM ENDORSEMENTS(FORM NUMBER) SEE ATTACHED. FORM SCHEDULE - WC990612 01/16/07 ASSIGNED RISK 66 Issue Date Issuing Office ABCDEF Authorized Representative WC 00 00 01 39967