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31B-167 (14) 137 ELM ST BP-2022-0039 , GIS#: ) COMMONWEALTH OF MASSACHUSETTS Map:Block: 31B- 167 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: ROOF BUILDING PERMIT Permit# BP-2022-0039 Project# JS-2022-000063 Est.Cost: $21000.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: THOMAS MORIN 112460 Lot Size(sq. ft.): 31493.88 Owner: SMITH JUSTIN Zoning: URB(100)/ Applicant: THOMAS MORIN AT: 137 ELM ST Applicant Address: - Phone: Insurance: 162 PANDLETON AVE (413) 230-8076 WC CH ICOPEEMA01020 ISSUED ON:7/14/2021 0:00:00 TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE ROOF POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: Service: Meter: • Footings: Rough: Rough: House# Foundation: Driveway Final: Final: Final: Rough Frame: Gas: Fire Department Fireplace/Chimney: Rough: Oil: Insulation: Final: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTH MPTO UPT IOLATION OF ANY OF ITS RULES AND REGULATIONS. I i Certificate of Occupancy Signature: FeeType: Date Paid: Amount: Building 7/14/20210:00:00 $40.00 3 212 Main Street, Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner // H i scloge -OK <-(C1 � �i S, The Commonwealth of Massa us l Board of Building Regulations and ►: 14 7 �� s R :.:0 Massachusetts State Building Code,780 A'vro, <'O? CT, ITY ' a�1o,,� I U 7. Building Permit Application To Construct,Repair,Renovate $ ish a Revis "Mar 2011 One-or Two Family Dwelling 61ga7O2, /" This Section For Official Use Only °so %. / Building Permit Number 40" A 3a 31 Date Applied: '' Ir ;% N I��fi' 70 Building Official(Print Name) f Signature I, to SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 137 elm s-0- At I -7 1.1 a Is this an accepted street?yes no Map Num Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ private❑ Zone: — Outside Flood Zone? Municipal❑ On site disposal system 0 Check if yes❑ SECTION 2 "PROPERTY OWNERSHIP' 2.1 Owner'of Record: M Name(Print) City,State,ZIP 137 c-(vn Si ay!7-3oI-1414:Vusk Sr,;+h Aoo(a4?`yn►a.l 44kh No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2,(check all that apply) New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0 Demolition ,.0 Accessory Bldg.0 Number of Units .n Other 'Specify BP it- Brief Description of Proposed Work2: "�g,,rtau� 64*di%r g° SECTION 4:ESTIMATED CONSTRUCTION COSTS Estimated Costs: Item Official Use Only (Labor and Materials) 1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ ❑'Standard City/Town Application Fee 0 Total Project Costa(Item 6)x multiplier x 3.Plumbing $ 2. Other"Fees: 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Fees: Check No. 3a Itt"Check Amount 6.Total Project Cost: $ 'Z(' a Igo 0 Paid in Full 0'Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) / i 1 116 ? / 3/? �t r, License Number Expiration Date Name of CSL Holder � r n List CSL Type(see below) l/ ++.and Street Type; Description. 35,000 Cu.ft.) LAW'UT-k A �D�-f] R Restricted &2 Family Dwelling // City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances l ).3o,a 7fo ouitX leg Lcc'w.t-isvn 6-3 L Insulation Telephone mail address D Demolition 5.2 Registered Home Improvement Contractor(HIC) )1.r/yS) 14/221A___ �O vG II `� K4 "''� HIC Registration Number piration Date HIC_ Q' Any Name or Hl Registrant Name /1P {'eruj'ekor "t— IJ4BC y 1p:dr,4nJt 442.8 (AI No.and Street Email address G)41x.0 1N1 OFF o to s o �//3.X300070 City/Town,State,ZIP Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c152.§25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the Issuance of the building permit. Signed Affidavit Attached? Yes 0 SECTION 7a,OWNERAUTHORIZATIONTO BE COMPLETED WHEN. OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize ' onvi. to act on my behalf,in all matters relative to work authorized by this building permit application.> emirs �rw�' 7/ / .2 1 Print Owner's Name(Electronic Signature) Date SECTIOON 7b:OWNER1 OR AUTHORIZED AGENT DECLARATION - By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. ol+►h•t _ _ l„,d./ Print Owner's or Authorized Agent's Name(Electronic Signature) Date NOTES: 1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) a(/D"Oa (including garage,finished basement/attics,decks or porch) Gross living area(sq.ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" The Common wealth of Massachusetts Department of Industrial Accidents 1 Congress Street,Suite 100 A Boston,MA 02T14-2017 ivww.massgot'/dia %Yorkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WiTU THE PERMITTING AUTHORITY. Applicant Information Please Print Leeihly Name(Business'O anizationrindividual): al/ KoJ r 4-611. vA. +►'‘ ,.Witriis, Address: /6�- .Qe `�/'"' - City,'State/Zip:.0114- rT ,61 dt Phone#: 1 f/3 `-,A.3Q- b 0--71„ - Are you an employer?Cheek the appropriate box: Type of project(required): 1.9 I am a employer with employees(full and'or part-time).' 7. Q New construction 10 Iam a sole proprietor or partnership and have no employees working 1 r mt in K. I Remodeling any capacity_[No workers'comp.insurance required.] 3 m I am a lwro izer doing all u-ork myself.INO wort:me eomp.insurance required.]t 9. 0 Demolition l 0 0 Building addition 4.Q l am a honkrowner and will L.a hiring contractors to conduct all work on my property. 1 will t--+ n ure that all contractors either have workers'compensation insurance of an:sole no Electrical repairs or additions proprietors with no ernpluyc . 12.0 Plumbing repairs or additions 5ai 1 am a teneral contractor and I have hired the sub.cuntractura Listed on the auudied sheet. 1.3.0 Roof repairs 'Chem:sob-contractors have employs,and Irry a workers'camp.ituuramt.t n nn �p ......4.- 6.0 W.an.a corporation and its,officers have exercised their right of exemption per MGL es. 14_ Other Qna.I2 Ke(�G r. .. 151,s 1(3),and we have no enrployrces.[No workers'Bump.insurance required.] i *Any applicaut that checks box sl must also till out the section below shutting their warf:ars'compensation policy information. t Flomeowm�rs who submit this affidavit indicating they are doing all work and then hue outside contractors must submit a new affidavit indicating such. :Contractors that cheek this box must attached an additional sheet showing the name of the subcontractors and state whether or not throat entities have employees. If the sub-contractors Ewe employees,they must provide their workara camp.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: • - , = . - Policy#-or Self-ins.Lic.#: .- • Expiration Date: - Job Site Address: - ' - CityiStaterZip: - . Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL e. 152, §25A is a criminal violation punishable by a fine up to$1,500.00 andtor 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 the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties afperjrrrythat the information provided above's true and correct. Siettatun' Date: 7 1 al . v � Phone#: 14)3 o13 O)67 to Official use only. Do not write in this area,to be completed by city or town officiaL City or Town: : - • - . Pernlit.1Liccnse# V Issuing Authority(circle one): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.PlumbIng Inspector 6.Other - . Contact Person: . . . Phone#: . City of Northampton •?o o,� S.w.. .S :ri,�ti Massachusetts /oi�r DEPARTMENT OF BUILDING INSPECTIONS 'y; ar' 212 Main Street • Municipal Building %.3%. Northampton, MA 01060 ss _ ^o� CONSTRUCTION DEBRIS AFFIDAVIT (FOR ALL DEMOLITION AND RENOVATION PROJECTS) In accordance of the provisions of MGL c 40, S54, a condition of Building Permit Number is that all debris resulting from this work shall be disposed of in a properly licensed waste disposal facility, as defined by MGL c 111, S 150A. The debris will be disposed of in: Location of Facility: Vy(/e./ The debris will be transported by: Name of Hauler: eo> ww Signature of Applicant Date: -7 Ii 44 City of Northampton Massachusetts �5 `.�,crt` '`► `� iyr DEPARTMENT OF BUILDING INSPECTIONS p41,7 212 Main Street a Municipal Building Northampton, MA 01060 a%W.3;1 HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT I, (insert full legal name), born_(insert month, day,year),hereby depose and state the following: 1. I am seeking a building permit pursuant to the homeowners'exemption to the permit requirements of the Massachusetts State Building Code, codified at 780 CMR 110.R5.1.3.1, in connection with a project or work on a parcel of land to which I hold legal title. 2. I am not engaged in, and the project or work for which I am seeking the aforementioned homeowners' exemption, does not involve the field erection of manufactured buildings constructed in accordance with 780 CMR 110.R3. 3. I qualify under the State Building Code's definition of"homeowner"as defined at 780 CMR 110.R5.1.2: Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one-or two-family dwelling, attached or detached structures accessory to such use and/or farm structures.A person who constructs more than one home in a two-year period shall not be considered a home owner. 4. I do not hold a valid Massachusetts construction supervision license and, except to the extent that I qualify for and will abide by the Massachusetts State Building Code's requirements for the supervision of the project or work on my parcel, I am not engaged in construction supervision in connection with any project or work involving construction, reconstruction, alteration, repair, removal or demolition involving any activity regulated by any provision of the Massachusetts State Building Code. 5. If I engage any other person or persons for hire in connection with the aforementioned project or work on my parcel,I acknowledge that I am required to and will act as the supervisor for said project or work. Signed under the pains and penalties of perjury on this day of ,20_. (Signature) ACCPREP MI CERTIFICATE OF LIABILITY INSURANCE DATE(MDD'Y„YY) 0/28/2020 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,thepolicy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on. this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Jennifer Hamel NAME: Southwick Insurance Agency PHONE (413)569-5541 FAX No): (413)569-6530 IA/C.No,Eidl: 562 College Hwy EMAIL Jhamel southwicionsa en ADDRESS:. Jhamel@southwickinsagency.com cycom INSURERS)AFFORDING.COVERAGE NAIC C •Southwick MA 01077 INSURERA: Crum&Forster Specialty Insurance Company 44520 INSURED INSURER B: Thomas Morin DBA Valley Roofing&Restoration INSURER C: 162 Pendleton Ave INSURER D: INSURER E: Chicopee MA 01020 INSURER F:. COVERAGES CERTIFICATE NUMBER: CL20102803454 REVISION NUMBER: 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 AdUfuBH - POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MMIDD/YYYY) (MMIDD/YYYY) LIMITS X COMMERCIAL.GENERALLIABIIM" EACH OCCURRENCE S 1,000,000 'CLAIMS-MADEOCCUR DAMAGE TO RENTED 100,000 PREMISES(Ea occurrence) S — MED EXP(Any one person) S 5,000 A BAK-69939-1 09/25/2020 09/25/2021 PERSONAL BADVINJURY S 1,000,000 GENLAGGREGATE MIT APPLIES PER: GENERALAGGREGATE S 2,000,000' X POLICY❑j CT LOC "PRODUCTS-COMP/OP AGG S 2,OOD,000 OTHER: _ 5 AUTOMOBILE LIABILITY COMBINED SINGLE UMIT s — IEa occident) ANY AUTO — OWNED — BODILY INJURY(Per person) S OWNED SCHEDULED AUTOS ONLY AUTOSBODILY INJURY(Per accident). S HIRED NON-OWNED PROPERTY DAMAGE 5 AUTOS ONLY AUTOS ONLY IPer accident) $ — UMBRELLA UAB" OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I RETENTION 5 5 WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? El lA EL EACH ACCIDENT S (Mandatory In NH) EL DISEASE-EA EMPLOYEE S II yes,describe under. DESCRIPTION OF OPERATIONS below" EL DISEASE-POUCYLIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POUCIES'BE CANCELLED BEFORE THE.EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Peter Rosengarten ACCORDANCE WITH THE POLICY PROVISIONS. 46 Willowbrook Drive - AUTHORIZED REPRESENTATIVEEEjj kbnl Springfield MA 01129 I1 h/ At IIJ 'i J� ©198 0�t5 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are tered marks of ACOR CTHOMEE-01 ARODRIGUES ACQRUF , CERTIFICATE OF LIABILITY INSURANCE Wag °'1"r' 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.ALTERTHE 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,thepolicyr(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-requite an endorsement: A statement on. this certificate does not confer rights to the certificate holder in'lieu of such endorsement(s): PRODUCER AMt Mirante Agency LLC PHONE 272 Main Street Ste 1 !(NC;No,Eid)c(203)778-9676 I FAX NO:(203)778-9902 Danbury,CT 06810 F6s .> Y� ',; UtSURERIS)AFFOR�NGCOV13iAGE NAtCg a Ir p.NORTHFIELD INSURANCE COMPANY INSURED =<' INSURER B:The-Hartford 22357 CT HOME EVOLIl,TION LLC•,R r :-INSURER C: 63 BELLEVEUSST : INSURER D: Waerbury,CT06704; r NSURERE: ` t _• r .__.:,:.r/ S._,.E : _. 'INSURER F:. COVERAGES .t '._{ CERTIFICATEINUMBER: . . REVISION NUMBER: THIS IS TO'CERTIFY THAT"THE POLICIES OF INSURANCE�l:ISTED.BELOW HAVE BEEN.ISSUED TO THE INSURED:NAMED ABOVE FOR THE POLICY PERIOD. INDICATED: NOTWITHSTANDING AN EMENT TEI3{y,aOR CONDITION.OF ANY CONTRACTOR 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 CONDmONSOF SOCH#OLICIES.UMITSSHOWNiMA'Y HAVE BEEN REDUCED BY PAID CLAIMS. INSR :'"ADDLSUBR• ` t 1...._:':. POUCYEFF. •POLICY EXP LTR TYPE OF INSURANCE rl IUD]AND.• a, ,,POUCY,HUMBER (MMMINTYW) jjDDryyyyl UNITS A: X COMMERCIAL GENERA LIABILITY' .__ _ EACH OCCURRENCE $ 1;000,000 1 CLAIMS-MADE FYI.OccuR i t'WS418745�, y 3/23/2021 3/23/2022 DAMAGE TO RENTED 1;000,000 .. PREMISES(Ee awngnco S MED DtP(Any aneyerson) S. 5,000 _.'-'.- , PERSONALSADVINJURY_ S 2000,000 t,� 2,000,000' GENT-AGGREGATE LIMTFAPPLIEtiS PER .n,V fr GENERAL AGGREGATE S pRa ,s -y ,.„I G 2,000,000 X POLICY JECT. LOC j t,s PRODUCTS=COMP/OP"AGG. S OTHER: J ' t �. t v ?� yr `� '''`-` ... _ S. AVTO&IOB1LE UABIthY r COMBINED SINGLE LIMIT ' met)_ S___ _ _ ANY AUTO;; s , BODILY INJURY(Per oeiscn) S ='� Lt�'fy �''w-��� At NLY SCHEDULED - + r { ' •BODILY INJURY(Peracc,dent) S. .OpNN-:Op +.. , PROPERTY DAMAGE. _AUTOS ONLY AI,,,,, ONLY ,' i (Peraccidenti S _,, S UMBREILAUAB • OCCUR �� EACH OCCURRENCE s EXCESS UABAGGREGATE S WED' RETENTIONS a. z `' ..:a k1 S' B WORKERS COMPENSATION s : h La< w y, yf n PER (OTH- ANDEMPLOYERS'LUiHILITYIf `. , ' x , w o-- X STATUTE I ER�.�� __ YL! 06-804i 21084-181468' 3130/2021_ 3130/2022 , ` 100,000 ANY PROPRIErRRIPARTNER1EXECUTIVE l ` - .. . 6L EACH ACCIDENT S. OFFICERIMIEMBER EXCLUDED?-- ` NIA (Mandatory m NH) _ `, EL DISEASE EAEMPLOYEE S 100.000 liyess.'desalbeWider r i — 5 DESCRIP7IONOF OPERATIONS below --,,?� `- ELDISEASEj POUcYLIMR .$s Ol1,�00 1--Y7 .._ € . ,,, DESCRIPTION OF OPERATIONS!LOCATIONS/VEHICLES(ACORD'101,Addd=onal Remarks Schedule,maybe attached tmom space Is required) fr, CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE 'THEREOF, NOTICE WILL BE DELIVERED IN Thomas:Morin Valley Roofing and Restoration ACCORDANCE WITH THE POLICY PROVISIONS. 162 Pendleton Ave Chicopee,MA 01020 AUTHORIZED PRESENTATIVE I ACORD.25(2016103) 01988 2015 ACORD CORPORATION. All rights reserved. The ACORDname and:logo are,registered marks ofACORD _vunnUVnWeditn-ur iwassacf`ssints Division cif Professioaal;Licensure 4 Board of Building Re0ulations'and Standards Constrime i6itIS p rvisor 1 CS-112460 1 1=- ires:07/23/2022. THOMAS D 162 PENDLET©N AVE l,j CHICOPEE MA.Oz1020 i,' + ' !r<3IS J0- 1 Commissioner , r Ke"nriik wi.wi/r E'/.T109va44141/14 Office at Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Individual Registration Expiration OSI08lZ022 TOM MORIN D/B/A VALLEYROOFING AND_RESTORATION THOMAS MORIN-:, 162 PENDLETON AVE t CHICOPEE.MA 01020. Undersecretary