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90 WHARF ST - BUILDING INSPECTION (2) CITY OF SALEM 1 PUBLIC PROPRERTY .. ` DEPARTMENT \l.\rt�N II(7 W.WIIKG:JD:SREET •5ALF%1. `tASSAC tt iL1.1sJ1)I-- TF.1.:978•745-1595 #F.Vt:)78JiG7846 Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5 Debris, and the provisions of MGL c 40, S 54; Building Permit# - .- -_ is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c 111. S 1.50A. The debris will be transported by: ---� I flame of hauler) Flie debris will be disposed of in (name W facility) I:1l3LLCCl, U1'fa av) of d"11..1c .:I7t),IC1G1—_---- / �av CITY OF SALEM PUBLIC PROPRERTY t c. DEPARTMENT :<Ht1J::R1J:Y DAM:ULL MAYOR 12C WASHING1*0ra STREET • Siti-rm MAS5ACI It:'a:i is 01970 .Tu 978-743-9595 • FAX:978-740-9846 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Anolicant Information Please Print Leeibly Name(Busilxss/Orgaa�nintioNindividuai): y I I I Cg rrr✓s Sty U (_h Li Address: 1 /(J t� L�S c f .S i q City/State/Zip: Q 1 7 �) Phone 631—`T)77 Are you an employer? Check the appropriate box: Type of project(required): I.❑ 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. �• ❑ Remodeling ship and have no employees These sub-contractors have S. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9• ❑ Building addition [Ko workers'comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their ME] Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL 1 1.❑ Plumbing repairs or additions myself. (No workers' cons c. 152,§1(4),and we have no y [ p. 12.❑ Rtwfnpairs insurance required.] t employees. [No workers' 13.0 Other comp. insurance required.] 'Any applicant that checks box HI must also fill out the section W,ow showing(heir worktas'cumpenudion pulley infurtrwtiun. ' lfumeuwncts who submit this at7ldavir indicating Ihcy arc doing all work and then him outside conuacron must submit a new afridavil indic ling suck tComnctun that check this box must attached an additional shecl showing the name of the sub-contractors and their workers'comp.policy information. fain mr employer that lv providing workers'compensation insurmrce fur ray employees. Below is rile policy and job site infonnutiom Q fnsurance Company Name: SSuc-?Cc._...._ c"• `e Policy x or Self-ins. Lie.it: VA CC S00I>� .,, I eJ Expiration Date: 3) 11 oo 6 p Job Site Address: �0 L", .5'i"l,- City/StateiZip: VK t Attach a copy of life workers'compensation policy declaration page(showing the policy number and expiratiun date). Failure to secure coverage as required under Section 25A of:VIGL c. 152 can lead to the imposition of criminal penalties of a tine up to S1.500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine Of up to S250.00 a day against [lie violator. Be advised that a copy of this statement may be forwarded to the Office of hlvesligatirms ul the DIA for insurance coverage verification. l du hereby certify under the wins and p dries afperjury that the information provided above is true and correct. S1L':lnlnre' `� �7 r-� Dat f I Ojjicial use only. Do not tvrire in this area.to be cwupleted by city or town ojjiriul. City or Town: . ._.._ __— Per mit/License Issuing Authority (circle one): 1. Board of llcallh 2. Building Department 3.City/foam Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.0(her Contact Person: _ Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for theirbniploydks. 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." ;fin 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, g25C(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, IvIGL chapter 152, §25C(7)stales"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for 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-contractors) name(s),address(es)and phone nunmber(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 cant'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 till out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to till 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 Elie 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 tilled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to bur leaves etc.)said person is NOT required to complete this affidavit. The Otlwe of Investigations would like to thank you in advance fur your cooperation and should you have any questions, please du not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial 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 5-26-05 www.mass.gov/dia x ✓fie (9mr�vr„�,r+;i¢aU,i o�✓�'LRCNarleuQ¢ ..\ ,� A � BOARD OF BUILDING REGULATIONS t� t s i icense CONSTRUCTION N SUPERVISOR SUP I+ umber CSl054710 Birth!,i aE. te- 7 /03J19 2QQ7 Tr. no: 11742 _ ResInc ed' THOMAS M ROCI(j7 OQ 190 PLEASANT STREfT�,. '.1�' MARBLEHEAD, MA 01945 C i missioner NOTICE NOTICE TO r TO EMPLOYEES EMPLOYEES f The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston, Massachusetts 02111 617-727-4900 As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will give you ;. notice that I(we) have provided for payment to our injured employees under the above mentioned chapter by insuring with: ASSOCIATED EMPLOYERS INSURANCE COMPANY NAME OF INSURANCE COMPANY 54 THIRD AVENUE, P.O. BOX 4070, BURLINGTON, MA 01803-0970 ADDRESS OF INSURANCE COMPANY WCC 5001342012007 03/11/2007 - 03/11/2008 POLICY NUMBER EFFECTIVE DATES 24 Federal Street 4th Floor Boston Insurance Brokerage Inc Boston, MA 02110 (617)556-7000 NAME OF INSURANCE AGENT ADDRESS PHONE Village Construction Inc 190 Pleasant Street Marblehead, MA 01945 EMPLOYER ADDRESS 01/26/2007 EMPLOYER'S WORKERS COMPENSATION OFFICER(IF ANY) DATE MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. -----—The-reasonable-cost-of-the-services-provided by-the-treating-physician-will-be paid-by the-insurer,if the-treatment-is necessary- -- ------ and reasonably connected to the work related injury. In cases requiring hospital attention,employees are hereby notified that the insurer has arranged for such attention at the NEAREST AND BEST MEDICAL FACILITY NAME OF HOSPITAL ADDRESS TO BE POSTED BY EMPLOYER WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE Associated Employers Insurance Company Burlington, Massachusetts (800) 876-2765 NCCI NO 40959 POLICY NO. I WCC 5001342012007 PRIOR NO. I WCC 500IT 2012006 ITEM 1. The Insured Village Construction Inc Mailing Address: Mr Michael Rockett Marblehead MA 01945 190 Pleasant Street (No. Street Town or City County State Tip Code ❑ Individual ❑ Partnership ® Corporation ❑ Other FEIN 04-3241709 Other workplaces not shown above: 2. The policy period is fron,03/11/2007 to 03/11/2008 12:01 a.m.standard time at the insured's mailing address. 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 work in each state listed in item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 500,000 eachaccident Bodily Injury by Disease $ 500,000 policylimit Bodily Injury by Disease $ 500,000 eachemployee C. Other States Insurance: COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06 A D. This policy includes these endorsements and schedules: SEE SCHEDULE 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. Classifications Premium Basis Rates Code Estimated Per$tea Estimated No. Total Annual of Annual Remuneration Remuneration Premium INTRA 137531 SEE EXT NSION OF INFORI 1ATION PAGE Minimum premium$ 500.00 Total Estimated Annual Premium $ 12,403.00 As indicated,interim adjustments of premium shall be made: - Deposit Premium $ 3,227.00 ❑ Annually ❑ Semi Annually ❑ Quarterly ® Monthly MA Assessment Chg. $12,030-48 x 4.1920% $504.00 This-policy,-including-all erMorsements--is-hereby countersigned-by_ _______ < _C-e-L�JG�_—- - —_____.09/26/2007 Authorized Signature Dale GOV GOV KIND PLACING CLAIM NAME SAFETY STATE CLASS AUDIT OFFICE I OFFICE I CHECK I GROUP Boston Insurance Brokerage Inc MA 5606 18 1505 1 1 1 24 Federal Street 4th Floor WC 00 00 01 A(11-88) Boston,MA 02110 Includes copyrighted material c:iho National Council on Compensation Insurance, used with its permission. Installment Schedule 505 Re: Village Construction Inc WCC 5001342012007 03/11/2007 TO 03/11/2008 Total Premium: $12,403.00 MA Assessment: $504 .00 ------------------ Total: $12, 907.00 Payment Date Amount Due 03/11/2007 Premium Deposit $3, 226.75 04/11/2007 Premium Installment $1, 075. 15 O5/11/2007 Premium Installment $1,075. 15 06/11/2007 Premium Installment $1,075.15 07/11/2007 Premium Installment $1,075.15 08/11/2007 Premium Installment $1,075. 15 09/11/2007 Premium Installment $1,075. 15 10/11/2007 Premium Installment $1, 075.15 11/11/2007 Premium Installment $1, 075.15 12/11/2007 Premium Installment $1, 079.05 Title: Schedule of Locations Remarks: Village Construction Inc 190 Pleasant Street Marblehead, MA 01945 This endorsement is attached to the policy indicated below and is effective on Me date stated herein,at 12:01 AM.,standard 0me at the address of the insured as described in Me information page. Policy No. Group Expiration Date of Policy Effective Date of Endorsement Endorsement No. WCC 5001342012007 03/11/2008 03/11/2007 Issued to Additional Premium Return Premium Village Construction Inc ISSUED BY: ASSOCIATED EMPLOYERS INSURANCE COMPANY Countersigned Authorized Representative I Schedule of Endorsements Remarks: WC000000 A Policy Conditions WC000113 Terrorism Risk Insurance Extension Act Endorsement WC000311 A Voluntary Comp & Employers Liability WC000404 Pending Rate Change Endorsement WC000406 Premium Discount Endorsement WC000414 Notification of Change in Ownership WC200301 Appl Lim Liab WC200302 MA Assess WC200303 B MA Notice WC200306 A MA Lim Other States WC200403 MA Const Class Prem Adj Endorsement WC200405 MA Premium Due Date Endorsement WC200601 MA Canc WC200604 Massachusetts Policy Definition This endorsement is attached to the policy indicated below and is effective on the date stated herein,at 12:01 AM.,standard time at the address of the insured as described in the information page. Policy No. Group Expiration Date of Policy Effective Date of Endorsement Endorsement No. WCC 5001342012007 03/11/2008 03/I I/2007 Issued to Additional Premium Return Premium Village Construction Inc ISSUED BY: ASSOCIATED EMPLOYERS INSURANCE COMPANY Courdersigned l thodzed Representative WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY POLICY NO. WCC 5001342012007 EXTENSION OF INFORMATION PAGE ITEM 4.CONTINUED PAGE NO. 1 Estimated Tota Rates Per CODE l $100 of Estimated Annual Premiums CLASSIFICATION OF OPERATIONS NO Annual Remun- Subject to Remuneration emtion Modification All Other MA-20 Intrastate I.D. 137531 Village Construction Inc 190 Pleasant Street Marblehead, MA 01945 No. of Employees Per Location 11 LANDSCAPE GARDENING & DRIVERS 0042 If any 4.98 0 MASONRY NOC 5022 If any 15.67 0 ELECTRICAL WIRING - WITHIN BUILDING 5190 If any 4.18 0 CONCRETE OR CEMENT WORK - FLOORS, D 5221 If any 9.18 0 PAINTING OR PAPER HANGING NOC & SHO 5474 14, 705 6.85 1,007 Average Number of Employees: 2 CONTRACTOR - EXECUTIVE SUPERVISOR O 5606 127, 473 2.41 3,072 Average Number of Employees: 3 CLEANER - DEBRIS REMOVAL 5610 If any 5.89 0 CARPENTRY - DETACHED ONE OR TWO FAM 5645 85, 775 9.03 7,745 Average Number of Employees: 2 CLERICAL OFFICE EMPLOYEES NOC 8810 If any 0.15 0 BUILDINGS NOC - OPERATION BY OWNER 9015 25, 427 3.19 811 Average Number of Employees: 3 BUILDINGS - OPERATION BY OWNER OR 9015 9, 433 3.19 301 Average Number of Employees: 1 TOTALS $262,813 $12, 936 Total Average Number of Employees: 11 AP 4921.01 (9-89) WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY POLICY NO. WCC 5001342012007 EXTENSION OF INFORMATION PAGE ITEM 4.CONTINUED PAGE NO. 2 Rates Per . Estimated Total Estimated Annual Premiums CLASSIFICATION OF OPERATIONS CODE Annual $100 of NO. Remuneration Remun- Subject to All Other eration Modification MA-20 Intrastate I.D. 137531 03/11/2007 TO 03/11/2008 Total Scheduled Premium For Period 12,936 Employers Liability 9807 1.00% 129 500/500/500-Class 9807 Subject to Experience Modifier/Merit Rating 13,065 Experience Modification Factor 9898 0.9300 -915 INTRA < 137531 > Published Premium Adjusted By Experience Modifier/Merit Rating 9999 0.0000 12,150 Subject to ARAP Surcharge 12, 150 ARAP Surcharge < 137531 > 0277 1.0000 0 Premium Adjusted By ARAP 0.0000 12, 150 Terrorism Risk Ins. Act of 2002 - Certified Losses 9740 79 Total Estimated Standard Premium 9999 12, 150 Subject to Premium Discount 12, 150 Premium discount 0064 -110 Expense Constant 0900 284 Terrorism Risk Ins. Act of 2002 - Certified Losses 9740 79 Subject to Mass Assessment 12,030 Policy Total 12,403 Mass Assessment 4.1920 504 AP 4921.01 (9-89) WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 00 00 A 1st Reprint Effective April 1, 1992 Standard WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY In return for the payment of the premium and subject to PART ONE all terms of this policy,we agree with you as follows: WORKERS COMPENSATION INSURANCE A. How This Insurance Applies GENERAL SECTION This workers compensation insurance applies to bodily injury by accident or bodily injury by disease. A. The Policy Bodily injury includes resulting death. This policy includes at its effective date the Infor- 1. Bodily injury by accident must occur during the mation Page and all endorsements and schedules policy period. listed there. It is a contract of insurance between 2. Bodily injury by disease must be caused or ag- you(the employer named in Item 1 of the Informa- gravated by the conditions of your employment. tion Page)and us (the insurer named on the Infor- The employee's last day of last exposure to the mation Page). The only agreements relating to this conditions causing or aggravating such bodily insurance are stated in this policy.The terms of injury by disease must occur during the policy this policy may not be changed or waived except period. by endorsement issued by us to be part of this policy. B. We Will Pay We will pay promptly when due the benefits required B. Who is Insured of you by the workers compensation law. You are insured if you are an employer named in Item I of the Information Page. If that employer is C. We Will Defend a partnership, and if you are one of its partners, We have the right and duty to defend at our expense you are insured,but only in your capacity as an any claim,proceeding or suit against you for bene- employer of the partnership's employees. fits payable by this insurance. We have the right to investigate and settle these claims,proceedings or C. Workers Compensation Law suits. Workers Compensation Law means the workers or We have no duty to defend a claim,proceeding or workmen's compensation law and occupational suit that is not covered by this insurance. disease law of each state or territory named in Item 3.A.of the Information Page. It includes any D. We Will Also Pay amendments to that law which are in effect during We will also pay these costs, in addition to other the policy period. It does not include any federal amounts payable under this insurance, as part of any workers or workmen's compensation law, any fed- claim,proceeding or suit we defend: eral occupational disease law or the provisions of 1. reasonable expenses incurred at our request, any law that provide nonoccupational disability but not loss of earnings; benefits. 2. premiums for bonds to release attachments and for appeal bonds in bond amounts up to the D. State amount payable under this insurance; State means any state of the United States of 3. litigation costs taxed against you; America, and the District of Columbia. 4. interest on a judgment as required by law until we offer the amount due under this insurance; E. Locations and This policy covers all of your workplaces listed in 5. expenses we incur. Items 1 or 4 of the Information Page; and it covers all other workplaces in item 3.A. states unless you E. Other Insurance have other insurance or are self-insured for such We will not pay more than our share of benefits and workplaces.----- ---- -- _ _ _-_--costs-covered-by-this insurance-and other — 1 of 6 a 1991 National Comcil on Conn ensmloo Inatance. WC 00 00 00 A WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY Standard Effective April 1, 1992 1st Reprint insurance or self-insurance. Subject to any limits of workers compensation law that apply to: liability that may apply, all shares will be equal until a. benefits payable by this insurance; the loss is paid. If any insurance or self-insurance b. special taxes,payments into security or is exhausted, the shares of all remaining insurance other special funds,and assessments pay- will be equal until the loss is paid. able by us under that law. 6. Terms of this insurance that conflict with the F. Payments You Must Make workers compensation law are changed by this You are responsible for any payments in excess of statement to conform to that law. the benefits regularly provided by the workers Nothing in these paragraphs relieves you of your compensation law including those required be- duties under this policy. cause: 1. of your serious and willful misconduct; 2. you knowingly employ an employee in violation PART TWO of law; EMPLOYERS LIABILITY INSURANCE 3. you fail to comply with a health or safety law or regulation;or A. How This Insurance Applies 4. you discharge,coerce or otherwise discriminate This employers liability insurance applies to bodily against any employee in violation of the workers injury by accident or bodily injury by disease. Bodily compensation law. injury includes resulting death. 1. The bodily injury must arise out of and in the If we make any payments in excess of the benefits course of the injured employee's employment by regularly provided by the workers compensation you. law on your behalf,you will reimburse us promptly. 2. The employment must be necessary or inci- dental to your work in a state or territory listed in G. Recovery from Others Item 3.A. of the Information Page. We have your rights, and the rights of persons en- 3. Bodily injury by accident must occur during the titled to the benefits of this insurance,to recover policy period. our payments from anyone liable for the injury. You 4. Bodily injury by disease must be caused or ag- will do everything necessary to protect those rights gravated by the conditions of your employment. for us and to help us enforce them. The employee's last day of last exposure to the conditions causing or aggravating such bodily H. Statutory Provisions injury by disease must occur during the policy These statements apply where they are required by period. law. 5. If you are sued, the original suit and any related I. As between an injured worker and us,we have legal actions for damages for bodily injury by notice of the injury when you have notice. accident or by disease must be brought in the 2. Your default or the bankruptcy or insolvency of United States of America,its territories or pos- you or your estate will not relieve us of our du- sessions, or Canada. ties under this insurance after an injury occurs. 3. We are directly and primarily liable to any per- B. We Will Pay son entitled to the benefits payable by this in- We will pay all sums you legally must pay as dam- surance.Those persons may enforce our duties; ages because of bodily injury to your employees, so may an agency authorized by law. Enforce- provided the bodily injury is covered by this Employ- ment may be against us or against you and us. ers Liability Insurance. 4. Jurisdiction over you is jurisdiction over us for The damages we will pay,where recovery is per- purposes of the workers compensation law. We mitted by law, include damages: are bound by decisions against you under that 1. for which you are liable to a third party by rea- law, subject to the provisions of this policy that son of a claim or suit against you by that third _ are not in conflict with that law. _ ___ party to recover the damages claimed 5. This insurance conforms to the parts of the 2 of 6 a 1991 National Council on Ccnpenaalion lnsuuancc. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 00 00 A 1st Reprint Effective April1, 1992 Standard against such third party as a result of injury to Act of 1969(30 USC Sections 901-942), any your employee; other federal workers or workmen's compensa- 2. for care and loss of services; and tion law or other federal occupational disease 3. for consequential bodily injury to a spouse, child, law,or any amendments to these laws; parent,brother or sister of the injured employee; 9. bodily injury to any person in work subject to the provided that these damages are the direct cone- Federal Employers' Liability Act(45 USC Sec- quence of bodily injury that arises out of and in the tions 51-60),any other federal laws obligating course of the injured employee's employment by an employer to pay damages to an employee you; and due to bodily injury arising out of or in the course 4. because of bodily injury to your employee that of employment, or any amendments to those arises out of and in the course of employment, laws; claimed against you in a capacity other than as 10.bodily injury to a master or member of the crew employer. of any vessel; 11. fines or penalties imposed for violation of federal C. Exclusions or state law; and This insurance does not cover: 12. damages payable under the Migrant and Sea- I. liability assumed under a contract. This exclu- sonal Agricultural Worker Protection Act(29 sion does not apply to a warranty that your work USC Sections 1801-1872)and under any other will be done in a workmanlike manner; federal law awarding damages for violation of 2. punitive or exemplary damages because of bod- those laws or regulations issued thereunder, ily injury to an employee employed in violation of and any amendments to those laws. law; 3. bodily injury to an employee while employed in D. We Will Defend violation of law with your actual knowledge or We have the right and duty to defend,at our ex- the actual knowledge of any of your executive pense,any claim,proceeding or suit against you for officers; damages payable by this insurance.We have the 4, any obligation imposed by a workers compen- right to investigate and settle these claims,pro- sation, occupational disease,unemployment ceedings and suits. compensation,or disability benefits law,or any We have no duty to defend a claim,proceeding or similar law; suit that is not covered by this insurance. We have 5. bodily injury intentionally caused or aggravated no duty to defend or continue defending after we by you; have paid our applicable limit of liability under this 6. bodily injury occurring outside the United States insurance. of America,its territories or possessions, and Canada. This exclusion does not apply to bodily E. We Will Also Pay injury to a citizen or resident of the United States We will also pay these costs, in addition to other of America or Canada who is temporarily out- amounts payable under this insurance, as part of side these countries; any claim,proceeding, or suit we defend: 7. damages arising out of coercion,criticism,de- 1. reasonable expenses incurred at our request,but motion, evaluation,reassignment,discipline, not loss of earnings; defamation,harassment,humiliation, discrimi- 2. premiums for bonds to release attachments and. nation against or termination of any employee, for appeal bonds in bond amounts up to the limit or any personnel practices,policies, acts or of our liability under this insurance; omissions; 3. litigation costs taxed against you; 8. bodily injury to any person in work subject to the 4. interest on a judgment as required by law until we Longshore and Harbor Workers' Compensation offer the amount due under this insurance;and Act (33 USC Sections 901-950),the Non- 5. expenses we incur. appropriated Fund Instrumentalities Act (5 USC _ _Sections 8171-8.173),the Outer Continental Shelf Lands Act(43 USC Sections 1331-1356), the Defense Base Act(42 USC Sections 1651- 1654), the Federal Coal Mine Health and Safety 3 of 6 5 1991 National Council on Comprnm�ion 1¢swence. WC 00 00 00 A WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY Standard E ectiveApril 1, 1992 1st Reprint F. Other Insurance 2. The amount you owe has been determined with We will not pay more than our share of damages our consent or by actual trial and final judgment. and costs covered by this insurance and other in- This insurance does not give anyone the right to add surance or self-insurance. Subject to any limits of li- us as a defendant in an action against you to deter- ability that apply, all shares will be equal until the mine your liability.The bankruptcy or insolvency of loss is paid. If any insurance or self-insurance is ex- you or your estate will not relieve us of our obliga- hausted, the shares of all remaining insurance and tions under this Part. self-insurance will be equal until the loss is paid. G. Limits of Liability PART THREE Our liability to pay for damages is limited. Our limits OTHER STATES INSURANCE of liability are shown in Item 3.13. of the Information Page.They apply as explained below. A. How This Insurance Applies 1. Bodily Injury by Accident.The limit shown for 1. This other states insurance applies only if one or "bodily injury by accident-each accident" is the more states are shown in Item 3.C. of the Infor- most we will pay for all damages covered by this mation Page. insurance because of bodily injury to one or 2. I£you begin work in any one of those states after more employees in any one accident. the effective date of this policy and are not in- A disease is not bodily injury by accident unless sured or are not self-insured for such work,all it results directly from bodily injury by accident. provisions of the policy will apply as though that 2. Bodily Injury by Disease.The limit shown for state were listed in Item 3.A. of the Information "bodily injury by disease-policy limit" is the Page. most we will pay for all damages covered by this 3. We will reimburse you for the benefits required insurance and arising out of bodily injury by dis- by the workers compensation law of that state if ease,regardless of the number of employees we are not permitted to pay the benefits directly who sustain bodily injury by disease. The limit to persons entitled to them. shown for"bodily injury by disease-each em- 4. If you have work on the effective date of this ployee" is the most we will pay for all damages policy in any state not listed in Item 3.A. of the because of bodily injury by disease to any one Information Page, coverage will not be afforded employee, for that state unless we are notified within thirty Bodily injury by disease does not include dis- days. ease that results directly from a bodily injury by accident. B. Notice 3. We will not pay any claims for damages after we Tell us at once if you begin work in any state listed have paid the applicable limit of our liability un- in Item 3.C. of the Information Page. der this insurance. H. Recovery From Others PART FOUR We have your rights to recover our payment from YOUR DUTIES IF INJURY OCCURS anyone liable for an injury covered by this insurance. You will do everything necessary to protect those Tell us at once if injury occurs that may be covered rights for us and to help us enforce them. by this policy. Your other duties are listed here. 1. Provide for immediate medical and other serv- I. Actions Against Us ices required by the workers compensation law. There will be no right of action against us under this 2. Give us or our agent the names and addresses insurance unless: of the injured persons and of witnesses, and 1. You have complied with all the terms of this other information we may need. policy; and 3. Promptly give us all notices,demands and legal 4of6 5 I W I National Cowcil on Compv anion Insurance. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 00 00 A 1st Reprint Effective April 1, 1992 Standard papers related to the injury,claim,proceeding or D. Premium Payments suit. You will pay all premium when due. You will pay the 4. Cooperate with us and assist us,as we may re- premium even if part or all of a workers compensa- quest,in the investigation,settlement or defense tion law is not valid. of any claim,proceeding or suit. 5. Do nothing after an injury occurs that would in- E. Final Premium terfere with our right to recover from others. The premium shown on the Information Page, 6. Do not voluntarily make payments,assume obli- schedules, and endorsements is an estimate. The gations or incur expenses,except at your own final premium will be determined after this policy cost. ends by using the actual, not the estimated,pre- mium basis and the proper classifications and rates that lawfully apply to the business and work covered PART FIVE-PREMIUM by this policy. If the final premium is more than the premium you paid to us,you must pay us the bal- A. Our Manuals ance. If it is less,we will refund the balance to you. All premium for this policy will be determined by our The final premium will not be less than the highest manuals of rules,rates,rating plans and classifica- minimum premium for the classifications covered by tions. We may change our manuals and apply the this policy. changes to this policy if authorized by law or a gov- If this policy is canceled, final premium will be de- . emmental agency regulating this insurance. termined in the following way unless our manuals provide otherwise: B. Classifications 1. If we cancel, final premium will be calculated pro Item 4 of the Information Page shows the rate and rata based on the time this policy was in force. premium basis for certain business or work classifi- Final premium will not be less than the pro rata cations.These classifications were assigned based share of the minimum premium. on an estimate of the exposures you would have 2. If you cancel,final premium will be more than during the policy period. If your actual exposures are pro rata; it will be based on the time this policy not properly described by those classifications,we was in force, and increased by our short-rate will assign proper classifications,rates and premium cancellation table and procedure. Final premium basis by endorsement to this policy. will not be less than the minimum premium. C. Remuneration F. Records Premium for each work classification is determined You will keep records of information needed to com- by multiplying a rate times a premium basis. Remu- pute premium. You will provide us with copies of neration is the most common premium basis.This those records when we ask for them. premium basis includes payroll and all other remu- neration paid or payable during the policy period for G. Audit the services of: You will let us examine and audit all your records 1. all your officers and employees engaged in work that relate to this policy.These records include covered by this policy;and ledgers,journals,registers,vouchers, contracts,tax 2. all other persons engaged in work that could reports,payroll and disbursement records,and pro- make us liable under Part One(Workers Com- grams for storing and retrieving data. We may con- pensation Insurance) of this policy. If you do not duct the audits during regular business hours during have payroll records for these persons, the con- the policy period and within three years after the tract price for their services and materials may policy period ends. Information developed by audit be used as the premium basis.This paragraph 2 will be used to determine final premium. Insurance will not apply if you give us proof that the em- rate service organizations have the same rights we ployers of these persons lawfully secured their have under this provision. _ workers compensation obligations. 5 of 6 i 1991 National Council on Compensation In�uenc,, WC 00 00 00 A WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY Standard E ectiveApril 1, 1992 1st Reprint PART SIX-CONDITIONS If you die and we receive notice within thirty days A. Inspection after your death,we will cover your legal represen- We have the right,but are not obliged to inspect tative as insured. your workplaces at any time.Our inspections are not safety inspections.They relate only to the insurabil- D. Cancellation ity of the workplaces and the premiums to be 1. You may cancel this policy.You must mail or charged.We may give you reports on the conditions deliver advance written notice to us stating when we find. We may also recommend changes.While the cancellation is to take effect. they may help reduce losses,we do not undertake 2. We may cancel this policy.We must mail or de- to perform the duty of any person to provide for the liver to you not less than ten days advance health or safetylof your employees or the public. We written notice stating when the cancellation is to do not warrant that your workplaces are safe or take effect. Mailing that notice to you at your healthful or that they comply with laws,regulations, mailing address shown in Item 1 of the Informa- codes or standards. Insurance rate service organi- lion Page will be sufficient to prove notice. zations have the same rights we have under this 3. The policy period will end on the day and hour provision. stated in the cancellation notice. 4. Any of these provisions that conflict with a law B. Long Term Policy that controls the cancellation of the insurance in If the policy period is longer than one year and six- this policy is changed by this statement to com- teen days, all provisions of this policy will apply as ply with the law. though a new policy were issued on each annual anniversary that this policy is in force. E. Sole Representative The insured first named in Item 1 of the Information C. Transfer of Your Rights and Duties Page will act on behalf of all insureds to change this Your rights or duties under this policy may not be policy,receive return premium,and give or receive transferred without our written consent. notice of cancellation. t 6of6 5 1991 National Council on Compcnsztion Insuance. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 01 13 (Ed. 1-06) TERRORISM RISK INSURANCE EXTENSION ACT ENDORSEMENT This endorsement addresses the requirements of the Terrorism Risk Insurance Act of 2002 as amended and extended by the Terrorism Risk Insurance Extension Act of 2005. Definitions The definitions provided in this endorsement are based on the definitions in the Act and are intended to have the same meaning. If words or phrases not defined in this endorsement are defined in the Act, the definitions in the Act will apply."Act" means the Terrorism Risk Insurance Act of 2002, which took effect on November 26, 2002, and any amendments resulting from the Terrorism Risk Insurance Extension Act of 2005. "Act of terrorism" means any act that is certified by the Secretary of the Treasury, in concurrence with the Secretary of State, and the Attorney General of the United States as meeting all of the following requirements: a.The act is an act of terrorism. b.The act is violent or dangerous to human life,property or infrastructure. c.The act resulted in damage within the United States,or outside of the United States in the case of United States missions or certain air carriers or vessels. d.The act has been committed by an individual or individuals acting on behalf of any foreign person or foreign interest,as part of an effort to coerce the civilian population of the United States or to influence the policy or affect the conduct of the United States Government by coercion. "Insured terrorism or war loss" means any loss resulting from an act of terrorism (including an act of war, in the case of workers compensation) that is covered by primary or excess property and casualty insurance issued by an insurer if the loss occurs in the United States or at United States missions or to certain air carriers or vessels. "Insurer deductible" means: a. For the period beginning on November26,2002 and ending on December31, 2002, an amount equal to 1 %of our direct earned premiums,as provided in the Act,overthe calendaryear immediately preceding November26,2002. b. For the period beginning on January 1,2003 and ending on December 31,2003,an amount equal to 7%of our direct earned premiums,as provided in the Act,over the calendar year immediately preceding January 1,2003. c. For the period beginning on January 1,2004 and ending on December 31,2004,an amount equal to 10%of our direct earned premiums,as provided in the Act,over the calendar year immediately preceding January 1,2004. d. For the period beginning on January 1,2005 and ending on December 31,2005, an amount equal to 15%of our direct earned premiums,as provided in the Act,over the calendar year immediately preceding January 1,2005. e. For the period beginning on January 1,2006 and ending on December 31,2006, an amount equal to 17.5%of our direct earned premiums,as provided in the Act,over the calendar year immediately preceding January 1, 2006. f. For the period beginning on January 1,2007 and ending on December 31,2007, an amount equal to 20%of our direct earned premiums,as provided in the Act,over the calendar year immediately preceding January 1, 2007. Limitation of Liability The Act may limit our liability to you under this policy. If annual aggregate insured terrorism or war losses of all insurers exceed $100,000,000,000 during the applicable period provided in the Act, and if we have met our insurer deductible, the amount we will pay for insured terrorism or war losses under this policy will be limited by the Act, as determined by the Secretary of the Treasury. 5 2002-2005 National Council on Compensation Insurance,Inc. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 01 13 (Ed. 1-06) Policyholder Disclosure Notice 1. Insured terrorism or war losses would be partially reimbursed by the United States Government under a formula established by the Act. Under this formula, the Unted States Government would pay 90% for Program Year 4 and 85%for Program Year 5 of our insured terroism or war losses exceeding our insurer deductible. 2. The premium charged for the coverage this policy provides for insured terroism or war losses is included in the amount shown in Item 4 of the Information Page or in the Schedule in the Foreign Terrorism Premium Endorsement.(WC 00 04 22),attached to this policy. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsementis issued subsequentto preparation of the policy.) Endorsement Effective 03/11/2007 Policy No. 5001342012007 Endorsement No. Insured Village Construction Inc Premiiuum�$ Countersigned G �--p-L WC 00 01 13 Authorized Representative (Ed. 1-06) A 2002-2005 National Council on Compensation Insurance,Inc. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 03 11 A VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE ENDORSEMENT Policy Number: 5001342012007 Policy Effective Date: 03/11/2007 to 03/11/2008 Policy Change Number: Change Effective Date:03/11/2007 Insured: Village Construction Inc Company: Associated Employers Insurance Company Carrier Code: 40959 This endorsement adds Voluntary Compensation Insurance to the policy. A. How This Insurance Applies This insurance applies to bodily injury by accident or bodily injury by disease. Bodily injury includes resulting death. 1. The bodily injury must be sustained by an employee included in the group of employees described in the Schedule. 2. The bodily injury must arise out of and in the course of employment necessary or incidental to work in a state listed in the Schedule. 3. The bodily injury must occur in the United States of America, its territories or possessions, or Canada, and may occur elsewhere if the employee is a United States or Canadian citizen temporarily away from those places. 4. Bodily injury by accident must occur during the policy period. 5. Bodily injury by disease must be caused or aggravated by the conditions of your employment. The employee's last day of last exposure to the conditions causing or aggravating such bodily injury by disease must occur during the policy period. B. We Will Pay We will pay an amount equal to the benefits that would be required of you if you and your employees described in the Schedule were subject to the workers compensation law shown in the Schedule. We will pay those amounts to the persons who would be entitled to them under the law. C. Exclusions This insurance does not cover: 1. any obligation imposed by a workers compensation or occupational disease law, or any similar law. 2. bodily injury intentionally caused or aggravated by you. D. Before We Pay Before we pay benefits to the persons entitled to them, they must: 1. Release you and us, in writing, of all responsibility for the injury or death. 2. Transfer to us their right to recover from others who may be responsible for the injury or death. 3. Cooperate with us and do everything necessary to enable us to enforce the right to recover from others. If the persons entitled to the benefits of this insurance fail to do those things, our duty to pay ends at once. If they claim damages from you or from us for the injury or death, our duty to pay ends at once. E. Recovery From Others If we make a recovery from others, we will keep an amount equal to our expenses of recovery and the benefits we paid. We will pay the balance to the persons entitled to it. If the persons entitled to the benefits of this insurance make a recovery from others, they must reimburse us for the benefits we paid them. - F�Employers Liability Insurance Part Two (Employers Liability Insurance) applies to bodily injury covered by this endorsement as though the State of Employment shown in the Schedule were shown in Item 3.A. of the Information Page. 1 of 2 Copyright 1991 National Council on Compensation Insurance. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 03 11 A Schedule Designated Workers Employees State of Employment Compensation Law All Employees MA MA 2 of Copyright 1991 National Council on Compensation Insurance. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 04 04 (Ed.4-84) PENDING RATE CHANGE ENDORSEMENT A rate change filing is being considered by the proper regulatory authority. The filing may result in rate dif- ferent from the rates shown on the policy. If it does,we will issue an endorsement to show the new rates and their effective date. If only one state is shown in item 3.A of the Information Page,this endorsement applies to that state. If more than one state is shown there,this endorsement applies only in the state shown in the Schedule. Schedule State Massachusetts This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation on the policy.) Endorsement Effective 03/11/2007 Policy No. 5001342012007 Endorsement No. Insured Village Cousuuction Inc Premium$ 1mumnce Company. - . -. _. ___—_. .—_—.______.___.— Associated Employers Insurance Company Countersigned By WC 00 04 04 (Ed.4-84) Copyright 1983 National Council on Compensation Insurance. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 04 06 (Ed. 4-84) PREMIUM DISCOUNT ENDORSEMENT Policy Number: 5001342012007 Policy Effective Date: 03/11/2007 to 03/11/2008 Policy Change Number: Change Effective Date: 03/11/2007 Insured: Village Construction Inc Company: Associated Employers Insurance Company Carrier Code: 40959 The premium for this policy and the policies, if any, listed in Item 3 of the Schedule may be eligible for a discount. This endorsement shows your estimated discount in Item I or 2 of the Schedule. The final calculation of premium discount will be determined by our manuals and your premium basis as determined by audit. Premium subject to retrospective rating is not subject to premium discount. Schedule 1. State MA Estimated Eligible Premium First Next Next $10, 000 $190, 000 $1, 550, 000 Balance 2. Average percentage discount: 0.910 3. Other policies: q If there are no entries in Items 1, 2 and 3 of the Schedule, see the Premium Discount Endorsement attached to your policy number: Copyright 1983 National Council on Compensation insurance. Processed:01262007 WORKERS COMPENSATION AND EMPLOYERS LIABILITY COVERAGE CERTIFICATE WC 00 04 14 (Ed. 7-90) NOTIFICATION OF CHANGE IN OWNERSHIP ENDORSEMENT Policy Number: 5001342012007 Policy Effective Date: 03/11/2007 to 03/11/2008 Policy Change Number: Change Effective Date:03/11/2007 Insured: Village Construction Inc Company: Associated Employers Insurance Company Carrier Code: 40959 Experience rating is mandatoryfor all eligible members. The experience rating modification factor, if any, applicable to this certificate,may change if there is a change in your ownership or in that of one or more of the entities eligible to be combined with you for experience rating purposes. Change in ownership includes sales, purchases, other transfers, mergers, consolidations, dissolutions,formations of a new entity and other changes provided for in the applicable experience rating plan manual. You must report any change in ownership to us in writing within 90 days of such change. Failure to report such changes within this period may result in revision of the experience rating modification factor used to determine your premium. Copyright 1990 National Council on Compensation Insurance. Processed:0126/2007 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 20 03 01 (Ed.4-84) MASSACHUSETTS LIMITS OF LIABILITY ENDORSEMENT This endorsement applies only to the insurance provided by Part Two(Employers Liability Insurance)because Massachusetts is listed in item 3.A.of the Information Page. Our liability to you under Section 25 of Chapter 152 of the General Laws of Massachusetts is not subject to the limit of Liability that applies to Part Two(Employers Liability Insurance). This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation on the policy.) Endorsement Effective 03/11/2007 Policy No. 5001342012007 Endorsement No. Insured Village Constmclion Inc Premium$ Insurance Company Associated Employers Insurance Company Countersigned By WC200301 --(Ed.-4-84)--- - - - -- -- - ---- - - - -- - -- - - -- -- - - -- - - - WORKERS'COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 20 03 02 (Ed.5/86) MASSACHUSETTS-ASSESSMENT CHARGE Massachusetts General Laws,Chapter 152, Section 65,as amended by Chapter 572 of the Acts of 1985,establishes a workers compensation special fund and workers compensation trust fund. On behalf of the Department of Industrial Accidents(DIA),the insurance company providing workers compensation coverage is required to bill and collect an assessment charge covering the special and trust funds from insured employers and remit the amounts collected to the State Treasury. The assessment charge,which is determined by applying a rate(subject to annual change)to the standard premium developed under your policy,is shown as a separate item on the information page of the policy. The rate may be different for private employers and for the Commonwealth and its political subdivisions. The income derived from the assessment charge will be used to fund the operating expenses of the DIA and to fund certain employee benefits as described in Chapter 152. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation on the policy.) Endorsement Effective 0311112007 Policy No. 5001342012007 Endorsement No. Insured Village Construction Inc Premium$ Insurance Company Associated Employers Insurance Company Countersigned By WC 20 03 02 (Ed.5/86) -.. - - - - - - - - -- -- - - Copyright 1986 National Council on Compensation Insurance. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 20 03 03 B 2nd Reprint Effective July 26, 1999 Standard MASSACHUSETTS NOTICE TO POLICYHOLDER ENDORSEMENT This endorsement applies only to the insurance provided by the policy because Massachusetts is shown in Item 3.A.of the Information Page. 1. Rates and Premium The policy contains rates and classifications that apply to your type of business. If you have any questions regarding the rates or classifications,please contact your agent or us. You may obtain pertinent rating information by submitting a written request to us at our address shown on this endorsement. We may require you to pay a reasonable charge for furnishing the information. You may also submit a written request for a review of the method by which your classification,rates or premiums were determined. If you are not satisfied with the results of the review,you may appeal to the Commissioner of Insurance at the address shown in this endorsement. 2. Reserves or Settlement You may request a loss run which contains reserve and settlement information for claims that relate to the premium for this policy. Such a request must be in writing and should be sent to our address shown on this endorsement. We will provide you with that information within thirty(30)days of receipt of your request, and at reasonable intervals thereafter. If you have any questions or believe that we set unreasonable reserves or made unreasonable settlements that affected your premiums or losses,you may make a written request through your agent or directly to us for a meeting with our company representative. If you are not satisfied with the results of the meeting,you may make a written appeal to the Insurance Commissioner at the address shown on the endorsement. Addresses Commissionerof Insurance Company Address Division of Insurance Associated Employers Insurance Company Department of Banking and Insurance 54 Third Avenue One South Station P.O.Box 4070 Boston,MA 02210 Burlington,MA 01803-0970 Notes: This endorsement must be attached to a policy showing Massachusetts in Item 3.A.of the Information Page. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 20 03 06 A (Ed. 9-94) MASSACHUSETTS LIMITED OTHER STATES INSURANCE ENDORSEMENT PART THREE-OTHER STATES INSURANCE of the policy is replaced by the following: A. How This Insurance Applies: 1. We will pay promptly,when due,the benefits required of you by the workers compensation law of any state other than Massachusetts,but only if the claim for such benefits involves work performed by a Massachusetts employee. 2. If we are not permitted to pay the benefits directly to persons entitled to them under circumstances described in item 1. above,we will reimburse you for the benefits required to be paid. IMPORTANT NOTICE! If you hire any employees to work outside Massachusetts or begin operations in any state other than Massachusetts,you must obtain insurance coverage in that state and do whatever else may be required under that state's law,as this Limited Other States Endorsement does not satisfy the requirements of that state's workers compensation insurance law. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation on the policy.) Endorsement Effective 03/11/2007 Policy No. 5001342012007 Endorsement No. Insured Village Construction Inc Premium $ Insurance Company Associated Employers Insurance Company - - - Countersigned By WC 20 03 06 A (Ed.9-94) Copyright 1994 National Council on Compensation lioumnce. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 20 04 03 Original Printing Effective January 1,1991 Standard MASSACHUSETTS CONSTRUCTION CLASSIFICATION PREMIUM ADJUSTMENT ENDORSEMENT The premium for the policy may be adjusted by a Massachusetts Construction Classification Premium Adjustment factor. The factor was not available when the policy was issued. If you qualify,we will have an endorsement to show the premium adjustment factor after it is calculated. Notes: 1. Attach this endorsement to a policy showing Massachusetts,in Item 3.A.of the Information Page when an insured's credit adjustment factor is not available when the policy is issued. 2. An appropriate typewritten entry may be made in Item 4 of the Information Page instead of using this endorsement. Copyright 1991 National Council on Compensation Insurance. MASSACHUSETTS PREMIUM DUE DATE ENDORSEMENT WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 20 04 05 Original Printing Effective June 1,2001 Standard MASSACHUSETTS PREMIUM DUE DATE ENDORSEMENT Section D of Part Five of the Policy is replaced by this provision: PART FIVE PREMIUM D. Premium Payments is amended to read: You will pay all premium when due. You will pay the premium even if part or all of a workers compensation law is not valid. The audit and retrospective premiums shall be paid by the due date indicated on the billing statement. Copyright 2000 National Council on Compensation Insurance,Inc.All Rights Reserved.Reprinted with permission. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 20 06 01 (Ed.6-92) MASSACHUSETTS CANCELLATION ENDORSEMENT This endorsement applies only to the insurance provided by the policy because Massachusetts is shown in item 3.A. of the Information Page. The Cancellation Condition of the policy is replaced by the following: Cancellation 1. You may cancel this policy by mailing or delivering to us advance written notice requesting cancellation. Such cancellation shall not be effective until ten days after written notice is given by us to The Workers' Compensation Rating and Inspection Bureau of Massachusetts(Bureau), or until notice has been received by the Bureau that you have secured insurance from another company,whichever occurs first. 2. We may cancel this policy only if based on one or more of the following reasons: (i)nonpayment of premium;(ii)fraud of material misrepresentation affecting your policy;or(iii)a substantial increase in the hazard insured against. Such cancellation shall not be effective until ten days after written notice is given by us to you and The Workers' Compensation Rating and Inspection Bureau of Massachusetts(Bureau),or until notice has been received by the Bureau that you have secured insurance from another insurance company,whichever occurs first. 3. Any of these provisions that conflict with the law that controls the cancellation of this insurance policy is changed by this statement to comply with the law- This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated.(The information below is required only when this endorsement is issued subsequent to preparation on the policy.) Endorsement Effective 03/11/2007 Policy No. 5001342012007 Endorsement No. Insured Village Construction Inc Premium $ Insurance Company Associated Employers Insurance Company Countersigned by WC 20 06 01 (Ed.6/92) Copyright 1992 National Council on Compensation Insurance. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 20 06 04 (Ed I1-02) MASSACHUSETTS POLICY DEFINITION ENDORSEMENT In the General Section,Part A.-The Policy,is replaced by the following: This policy includes at its effective date the Information Page,all endorsements and schedules listed there, and your application for insurance. It is a contract of insurance between you(the employer named in Item I of the Information Page)and us(the insurer named on the Information Page). The only agreements relating to this insurance are stated in this policy. The terms of this policy may not be changed or waived except by endorsement issued by us to be part of this policy. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise staled. (The information below is required only when this endorsement is issued subsequent to preparation on the policy.) Endorsement Effective 03/11/2007 Policy No. 5001342012007 Endorsement No. Insured Village Construction Inc Premium$ Insurance Company Associated Employers Insurance Company Countersigned by WC-20-0604- -- -- -- - - - - - ---- --- - - - --- (Ed. 1 I-02) CrrrOFsALEn - PUBLIC PROPERTY DEPARTM&NT ri..mFs.ry ouscuu M"roe 13DmweawGww Tr%w*3n1yw mAnAca shm o,970 I%L•MUS-M•Fite M740."% APPLICATION FOR THE REPAIR. RENOVATION. CONSTRUCTION, DE.yIOLITION. OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING STRUCTURE OR BUILDING 1.0 SITE INFORMATION Locatlon Name: S r- Property is located In a;Conservation Arse YIN Historic DIskid YIN N 2.0 OWNERSHIP INFORMATION 2.1 Owner of Land Name: Address: a3 Coe�)V - S� SF ln-�. o f 7o Telephone9 9 `G- �7 o- 9 a 3.0 COMPLETE THIS SECTION FOR WORK IN E7IISIING BUILDINGS ONLY Addition Existing Renovation �p ouo Number of Stories Renovated Change in Use New Demolition Existing Approximate year of Area per floor (sf) Renovated construction or renovation 19 7 y of existing building New Brief Description of Proposed Work: t�CQ L° �op � 1r«. 1nJ rto-� Of bV. 1 ��� -- Mail Permit to: What is the current use of the Building? if dwelling.how many units? l S� Material of BuJding? � Asbestos? Witi the Building Conform to Law? Architects Name Address and Phone 1 Mechanies Name Address and Phone �—c{ Conatniction Supervisors it --7 It) HIC Registration 0 Estimated Cost of Projed S — Permit FN Calculation Permit Fee: o Q � Estimated Cost X=7151000 Residential - - Estimated CostX a11$1000 Commerclal -- - An Additional $5.00 is added as an r Administrative charge. Make sure that an fleids are properly and legibly written to avoid delays in processing. The undersigned does hereby apply for a Building Permit to build to the a e stated speciflcations. Signed under penalty of pedurY Date U Y n v I. V A � ac \ A F a C7� D `