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23D-033 (2) 55 MILTON ST BP-2022-0040 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:23D-033 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-2022-0040 Project# JS-2022-000064 Est.Cost: $10850.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: THOMAS MORIN 112460 Lot Size(sq.ft.): 8145.72 Owner: BISHOP MADISON Zoning: URB(100)/ Applicant: THOMAS MORIN AT: 55 MILTON ST Applicant Address: Phone: Insurance: 162 PANDLETON AVE (413) 230-8076 WC CHICOPEEMA01020 ISSUED ON:7/13/2021 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 NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. TI I yA 'I ► Certificate of Occupancy Signatu ' FeeType: Date Paid: Amount: Building 7/13/2021 0:00:00 $40.00 212 Main Street, Phone(413)587-1240, Fax: (413)587-1272 " Louis Hasbrouck—Building Commissioner REC I h The Commonwealth of Massachus tts JU' 1 It Board of Building Regulations and S ,ndar• i FO t Massachusetts State Building Code,7:0 C I' 2021 C•`AI'ITY oEpr U. Building Permit ApplicationOne-or Two Family Dwelling_To Construct,Repair, u •i0��`N��ON•MA�eC,�locoNS ised ar 2011 is Section For Official Use Only Building Permit Number a d Date Applied: �--- _ Building Official(Print Name) j Signature 14 Da e SECTION 1:SITE INFORMATION 1.1 eroverty Address: 1.2 Assessors Map&Parcel Number J J ONd �411 .5 f- Plorev��-C- 1.la Is this an accepted street?yes no Map Number 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 CI On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: PA a AiS014 ber,hot V16r Pl i WO OCa(a�. Nameme(Printt)n. Q t +'City,State,ZIIP+ // 1 /�, v Y r'�.clday. S O�O3�' 2 J 7_ / /1/ mli6C+)eykt,51ur (—`t ' vI• (AYr No.and Street Telephone Email Ad ess ��VJ SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building❑ Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg.0 Number of Units Other Pi Specify: -f ore• Brief Description of Proposed Work2: aN w e- q4 eQ l5 cL a no P 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 $ 0 Standard City/Town Application Fee ❑Total Project Cost3(Item 6)x multiplier . x 3.Plumbing $ 2: Other.Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire Suppression) $ Total All Fees: Check No.J 2 Check Amours 6.Total Project Cost: $/ 5s_O.oa ❑Paid in Full 0 Outstanding Balance Due: SECTION 5 CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) �/� G5 "/A 1/6a 7-.2 3-2) AlV � V b r- V N. License Number Expiration Date N e of CSL Holder i i G eeAA( �� List CSL Type(see below) No.and Street Type t Description ', G`D Unrestricted(Buildings up to 35,000 cu.ft.) (city(' R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances y(33a30 707p, 1/G///el goo� /�y 4.4 �WS r Insulation Telephone / mail address Demolition 5.2 Registered Homee Improvement Contractor(HIC) fy 05/o t/ i C iLoo 4wA R.esi --rh HIC Registration Number Expiration Date /G a LC Regi tolnet Name Q// //�� I a/4Ile/goat c.4 4-rc,c �O rx;•t-eat No. d StreeA Email address 1/14,14 0I0J. ) "tq/3,,A30)e p City/Town,State,ZIP Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE APFIDAVIT(M.G.L c.152`§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 El' No ❑ SECTION 7a:"OWNER-AUTHORIZATION TO BE-COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize 6 drXi,'�'Sr r`�✓ to act on my behalf,in all matters relative to work authorized by this building permit application. 0**14)440v 643110e 711.242/ Print Owner's Name(Electronic Signature) Date SECTION 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.✓tT'"t 1/1'te-A 7 //A /A./ 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.) /Of $"to (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 Commonwealth of Massachusetts ,. �. 19Department of Industrial Accidents s 1 Congress Street,Suite 100 Boston,MA 02114 2017 ti www.mass.gor/dia Workers'Compensation Insurance Affidavit:BuiIderslContractors/ElectriciansfPlumbers. TO DE FILED W'ITHTHE PER:1il'ITIYC Au`1'IHORITY. Annlicant Information -(`^ Please Print Lee_ihiv Name(BusincsifOrraniration/Individual): �6Y� �1. bCt� G �c a , c � Kc5 c'G oyN Address: 9 kO ? A'.)- n . �c/ I Phone • i 3�-3 0 6. 7 to City/State/Zip:-• o_ �1 0aii Are you an employer?Cheek the appropriate box: Type of project(required): 1.01 am a canployrs with - employees(full mirror pus-tiro).• 7• ®New construction 20 fain a sole proprietor or iaartnership and have rug ccuployers working, (Ur ose in 8_ 0 Remodeling any capacity.[No workers'comp.insurance nquincL) 9. []Demolition 30 I ant a hum owner doing all work myself_[No worke&comp_in urancc nquintl.]' 100 Building-addition 4.0 I am a homeowner and will to hiring Srttraiiora to conduct all work on my property_ I will n insure that all contractors either have workers'eormx,nsatiun insurance or am sole l 1 i�J Electrical repairs or additions proprietors with no tnnployecs. 12.0 Plumbing repairs or additions. S 1 ant a eerrer-al contractor and I I3ve hired the sub-contractors listed on the attached sheet 130 Rotlf rs'paira Thee sub-contractors lia►. employees and ion.cwurkcrs'comp.insurance.: _ 'Lott' 6.0 We a a corporation and its afticers have exercised their right of exemption perMIGL e_ I4.(�j Other {�Ba C L'?1t_ �rti I- m 1 2.a I(4).and we Irive nu employees.[Na wurkers'comp.insurance regnuze f.] 'TT^"' 'Any applicant that checks boat P.I must also fill out the section below showing their w orkcrs'conversation policy information_ t Homeowners ners who submit this aflidaait indicating they are doing all work and then hire outside contractors mast submit a new affidavit indicating such. :Contractors that cheek this box must attached an additional sheet showing the name of the sub,contractars and state whcihcror not those ctatities have rsnployccs. 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: - . Policy#or Self ins.Lic..#: Expiration Date: -. Job Site Address: . . . - ' ' CitylState 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 MMGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year irnprisonrnent,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 certifyhereby yc under the pains and penalties of perjury that the Information provided above Lc true and correct. Sienature: O C1 Date: —2 /1 a—/D ( Phone 4: '1.-( ^�✓1 r L3O'-‘iO' 1'0 official use only: Do not write in this area,to be completer)by city or town officIaL City or Town: - - - PermitfLicense h - - Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbhtg Inspector 6.Other . - Contact Person: ` - . Phone#: -- - City of Northampton `� ...i i off ,._ $cars. �«•"r'fl(JlC . ' Massachusetts 4 JYY' Si at �� DEPARTMENT OF BUILDING INSPECTIONS • 212 Main Street • Municipal Building 0\ Northampton, MA 01060 sbjy• 11 CONSTRUCTION DEBRIS AFFIDAVIT (FOR ALL DEMOLITION AND RENOVATION PROJECTS) In accordance of the provisions of MGL c 40, S54, a condition of Building Permit Number is that all debris resulting from this work shall be disposed of in a properly licensed waste disposal facility, as defined by MGL c 111, S 150A. The debris will be disposed of in: Location of Facility: 1 tin Qe_cy&L j The debris will be transported by: Name of Hauler: Signature of Applicant: Date: 7 ���/ City of Northampton lw+�.. sl 1 Massachusetts F��s` " l<<c 3- !✓ :!. DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building ruby is Northampton, MA 01060 d'$A aO 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) �1 CTHOMEE-01 ARODRIGUES ACOREY DATE(IIWODITYYII) `,� CERTIFICATE OF LIABILITY INSURANCE 3l2912021 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 POUCIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A'CONTRACT BETWEEN'THE ISSUING INSURER(S) AUTHORIZED REPRESENTATIVE OR PRODUCER,AND.THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the poiicy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WANED, subject to the terns and conditions of the policy,certain'policies may require an endorsem ent A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s)., PRODUCER NAND ACT Mirante Agency LLC PHONE �):(203)778-9676 I Fax 203 T78-9902 272 Main Street Ste 1 SAIA( (arc,No):( ) Danbury,CT 06810 ADDRESS: ~ INSURER(S)AFFORDING COVERAGE NAIC S JNSURF.RA:NORTHFIELD INSURANCE COMPANY INSURED i; - INSURERs:The Hartford 22357 CT HOME EVOLUTION LLC r . INSU C: 63"BELLEVEU ST INSURER D Waterbury,.CT 06704',a , , INSURER E c , - o ~ f___ .� .: INSURERF: COVERAGES c ...... ./. CERTIFICATE:NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT'THE POLICIES,OF INSURANCE'LISTED BELOW HAVE BEEN ISSUED TO THE INSURED.NAMED ABOVE FOR THE POUCY PERIOD. INDICATED_ NOTWITHSTANDING ANY REQUIREMENT TEf31U OR",CONDfITON OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAYS PERTAIN, THE'INSURANCE,AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH'POLIICIES.LMITS,'SHOWN-MAY HAVE BEEN,REDUCED BY PAID CLAIMS. INSR ti=-' ADDL SUER ` :' POLICY EFF POLICY EXP LTR TYPE OpOJSURANCE 1-'INSD WM \ POUCYNUMBER ORPARTINYYYY) (IIDMIDONYYYI LIMITS A X cOMIVlERCIAL GENERAL IJABILITY 1,000,000 EACH �I S'_ _ CLAIMS-MADE X -OCCUR WS418745 , 3123/2021 3/2312022 AMnGT9 TtFNTED 1,000,000 - 1 I. Y.. PREML4ES(Ea occurrence) S MED EXP(Ana one person) $ 5,000 `` PERSONAL&ADVINJURY $ 2,000,000 GENT_AGGREGATE , , ... ;i GENERAL AGGREGATE _.Y $ 2,000,000 poucr ( I LOC q' PRODUCTS-COMP/OP AGO S 2,000;000 ���) OTHER: "` $ -� COMBINED SINGLE LIMIT AUTOMOBXE LlABUJSY ' . .V.O e l.. S ANY AUTO; xr"., _" c:` ice' BODILY INJURY(Per person) S. OWNED SCHEDULED AUTOS ONLY, (A�pUPOS{�N , ,, BODILY INJURY(Per ac ident) $ HELM , AUTOS OI ED r`, (Pm-accident)tERTY PAMAGE S AUTOS ONLY - S UMBRELLAUAB _.00CUR '• i i ti _ EACH OCCURRENCE S EXCESSLUAB CLAIMS4 ADE ' AGGREGATE $ DED RETENTIONS i _" S B WORKERS COMPENSATION :'6-Fty ; - .._r STATUTE' ER AND EMPLOYERS-LIABILITY o `� =' __.___ YrN be-s041 21084-18tasa 3/3012021 3130 2022 100,000: ANY PROPRIETORlPARTNRLE)ECUTIVE *-.., E:L EACH ACCIDENT''''-. $ OFFICER/MEMBER EXCLUDED? NIA (Mandatory.in NH) ` EL DISEJASE EAE MPLOVEE S 100,000 If yes,describe under ", 500,000 DESCRIPTION OF OPERATIONS below EL.DISEASE-POIICYLIMO' S; r• � J 4 DESCRIPTION OF OPERATIONS T LOCATIONS 1 VElN1CLES(ACORD 101,Addlanal Remarks Schedule;may be atiaehed if More space is iequUed) J _ CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Thomas Morin ValleyRoofin and Restoration THE EXPIRATION -DATE THEREOF,. NOTICE WILL BE DELIVERED IN 9ACCORDANCE WITH THE POLICY PROVISIONS. 162 Pendleton Ave Chicopee,MA 01020 AUTHORED REPRESENIATIVE ACORD 25(2016103) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are:registered marks of ACORD ACC D CERTIFICATE OF LIABILITY INSURANCE DATEpl1MIDDIYYYY) 10/28/2020 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,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement-A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT -Jennifer Hamel Southwick Insurance Agency PHONE (413)569-5541 F 413 569 6530 fAIO No;Eat); (A/C,No): ( ) 562 College Hwy AooREss: Jhamei@southwickinsagencycom INSURERS)AFFORDING COVERAGE NAIC 0 Southwick MA 01077 INSUItEItA: Crum&ForsterSpedalty Insurance Company 44520 INSURED INSURERS: Thomas Morin DBA Valley Roofing&Restoration INSURER C: • _ 162 Pendleton Ave INSURER 0: INSURER E:. Chicopee MA 01020 INSURERF: 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 RESPECTTO.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 POUCIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR _ TYPE OF INSURANCE 1 ADDER/BR POLICY NUMBER (MMOIUDDY/Y YY) (MMIIDDIY—POLICY EYYYI UNITS X COMMERCIAL GENERALLIABIUTY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 1000 1 CLAIM n S-MADE 1'�.OCCUR PREMISES(Ea occurrence) $ ,00 — MED FJXP(Anyone person) S 5,000 A BAK69939-1 09I25/2020 09/2$/2021, PERSONAL&ADV INJURY S 1,000,000 GGEEMLAGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE S: 2,000,000, RPRODOTHER:n jEC LOC UCTS-COMP/OP AGG S 2,000,000 OTHER: S AUTOMOBILE UABIUTY COMBINED SINGLE LIMIT $ (Ea accident) — ANY AUTO BODILY.INJURY(Per person) $ OWNED ^SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE S -AUTOS ONLY AUTOS ONLY (Per accident] S UMBRELLA UAB OCCUR EACH OCCURRENCE S EXCESS UAB CLAIMS-MADE AGGREGATE S _ DED.1 1 RETENTION S S _ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY Y I NY PER TUTE I ER ANY PROPRIETOR/PARTNERIE 1 1 XECUTIVE NIA EL EACH ACCIDENT S OFFICER/MEMBER EXCLUDED? (Mandatory in NH) EL DISEASE-EA EMPLOYEE S If yes,describe under DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY UMIT S DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES-(ACORD 101,Additional Remarks Schedule,maybe attached if more space is required) CERTIFICATE HOLDER. "CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Peter Rosengarten ACCORDANCE WITH THE POLICY PROVISIONS. 46 Willowbrook Drive AUTHORIZED RE PRESENTATIVE /� I Springfield MA 01129 * At J Ai-ja( n/f / ©19885 ACORD CORPORATION. All rights served. ACORD 25(2016103) The ACORD name and logo are gisitered marks of ACO „siumunuffwea un-ormassac,rms,cris Division.of Professional Licensure ”' , - Board of Building Regulations and,Standards ConstruLiaii'1 pprvisor = , CS-112460 > i E ires: 07/23/2022: • THOMAS D MORIN �s{_ a 162 PENDLETON AVE4 ffi+ a ,,- f �tja� t Commissioner Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Individual Registration Expiration 8Fi148' 08/08/2022 TOM MORIN D/B/A VALLEY.RODFING.ANURESTORATION THOMAS MORIN a /� 162 PENDLETON AVE. " ` :CHICOPEE,MA 01020'' Undersecretary