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Building Permit #814-2017 - 64 MEADOW LANE 3/2/2017
Permit No#: 31 L(- 9-0 17 BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION )--;�_V/% Date Received t3 17 TYPE OF IMPROVEMENT PROP ED USE Res' ential Non- Residential ❑ New Building One family ❑ Addi ' n ❑ Two or more family ❑ Industrial ❑ ration No. of units: ❑ Commercial P"Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other Septic ❑_,Well - ID Floodplain Wetlands Water hs ed!Disti ict bi Water/Sewer, 4 DESCRIPTION OF WORK TO BE PERFORMED: iIV S -rt uCrL) n - q - L. C oA4/GES�,) Identificati P�ease Type or Print C1earIy OWNER: Name:/%-P �d o Address: , V( C 14 LJ q7$-60- 733 Contractor'Na-a Rober*_.Pbczo b P- hone:__ /� rr vin /VL A - Address:. !r��� SyL--,. . , _ l� Supervisor's Consfruction. License _.Exp. Date: Homerlmprovement,License:.. ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE. BOLDING PERMIT. $12.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $925.00 PER S.F. 00 Total Project Cost: $r FEE: $ Check No.: Receipt No,;_ NOTE: Persons contracting with unregistered contractors do not have-acces to the gua anty fund _g f�✓ �, Signature of contract lJG' Si nature o A nt/Owner five Plans Submitted ❑ Plans Waived 0 Certified Plot Plan ❑ Stamped Plans ❑ TYPO F SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private (septic tank, etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On COMMENTS Signature. CONSERVATION Reviewed on Siqnature COMMENTS HEALTH COMMENTS Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Planning Board Decision: Comments Zoning Decision/receipt submitted yes Conservation Decision.- Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Located M4 FIRE DEPARTMENT - Temp Dumpster on site yes no Located,.at 124.Main Street Fire. Department signature/date COMMENT Street limension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A —F and G min.$10041000 fine Doe.Building Permit Revised 2014 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application o Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H. I. C. And C. S. L. Licenses o Copy Of Contract o Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) a Copy of Contract o Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products VOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc: Building Permit Revised 2014 Location iC y i41 No.1 r 7`' —do,7 Date d �� Check # VO -747 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ / Foundation Permit Fee $ „ Other Permit Fee $ TOTAL $ / Building Inspector 0 CD� Z CD 0 Cr Q c• 0 0 0 CD CrCL 2) CD 0 C" I a CD0 cm• CD CSD 0 0 U) 0 U) cn' 0 r_ cn LU CD n 0 CD CD a. CO) CDN v Z CD 0 CD 0 0 0 0 O 2 r- Cn = < (D -0 N O O• CL CD n � CD 0 • 0 0 CL n .+• O Z p=r-0 N O� O N ,..r 5• C ?1Oo O O rt Q Fn_ N W p cn m -0NCC 2 O fl' a CD O O O O 0 � c r. no -446 o �• , ~n rt CD -t3 t �� �o� 3 rm 0<� O O O N Lip "C o o - EL cn > C7 N y�_ C Q. 0 —_ CQ N � Q_ O n N O O M U) O O �• CO) CD � 0 _ U) CL � O CA 0-0 rt) 0 W v+ rt :4w Q Axcn CD 'S 2 ;, OF p't cn ?` c CD = �tS` s o Z I zk =� v_ CD ±� C z -So s �D m rt -a rn � o 23 � rt C) O CL O N O 77 O V) N O z O W c j T o m -ZI T v ]J O c cm M Na H O T N N N Z7 c OL1 m m n D M m 0 T N �f,7 c Qq C W m 0 T n=i (") S C .Z7 c Qq T c l O 3 W c v z G1 m 0 VI 'B ( rD 3 T O h CDS ' W O m _ I Home Depot Contractor License Numbers: MA Home Improvement Contractor Reg. # 126893 Salesperson Name and Registration Number: Leonard Racite : R-1-073-14-00023 Home Improvement Agreement Home Depot U.S.A., Inc. ("Home Depot") or Service Provider named below will furnish, install and/or service the equipment listed below at the price, terms and conditions as outlined on this form. Customer Information: Laura Medolo [Boston North 9851519 —� First Name Last Name Branch Name Lead # 64 Meadow Ln, North Andover, MA FORTH ANDOVER MA 01845 Customer Address City State Zip (978) 683-7383 1 11 —� Home Phone# Work Phone# Cell Phone# tonylaura25@verizon.net NOTICE OF RIGHT TO CANCEL: YOU MAY CANCEL THIS AGREEMENT WITHOUT PENALTY OR OBLIGATION BY DELIVERING WRITTEN NOTICE TO HOME DEPOT AT: 908 Boston Turnpike Unit 1 Shrewsbury MA 01545 Address City State Zip or Email CustomerCancellationNorthEast@homedepot.com BY MIDNIGHT ON THE THIRD BUSINESS DAY AFTER SIGNING, UNLESS THE STATE SUPPLEMENT PROVIDES A different CANCELLATION PERIOD. THE STATE SUPPLEMENT CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN YOUR STATE. YOUR PAYMENT(S) WILL BE RETURNED WITHIN TEN (10) BUSINESS DAYS AFTER HOME DEPOT'S RECEIPT OF YOUR NOTICE. YOU MUST MAKE AVAILABLE FOR PICKUP BY HOME DEPOT OR PROFESSIONAL, AT YOUR SERVICE ADDRESS, AND IN SUBSTANTIALLY THE SAME CONDITION AS WHEN DELIVERED, ANY MERCHANDISE OR MATERIALS DELIVERED TO YOU. OR YOU MAY CONTACT HOME DEPOT FOR INSTRUCTIONS REGARDING RETURN SHIPMENT AT HOME DEPOT'S EXPENSE. THE LAW REQUIRES THAT THE CONTRACTOR GIVE YOU A NOTICE EXPLAINING YOUR RIGHT TO CANCEL. PLEASE SIGN BELOW TO ACKNOWLEDGE THAT YOU HAVE BEEN GIVEN ORAL AND WRITTEN NOTICE OF YOUR RIGHT TO CANCEL. Acknowledged by: 02/16/2017 Date Contract Price and Payment Schedule: Payment of the Contract Price is due upon completion unless a different payment schedule is specified in the State Supplement. Includes all applicable discounts, rebates, and , taxes. Contract Price $ 5977.50 Excludes finance charges.* Minimum % deposit $ Due Immediately Remaining balance $ Due upon completion Finance Charges *Any interest payments or other finance charges will be determined by Customer's separate cardholder or loan agreement, to which The Home Depot is NOT a party, and will be in addition to Customer's payment under this Agreement. Customer is subject to the terms and conditions of the cardholder or loan agreement, as applicable. No funds should be made payable to Service Provider; however, Service Provider may collect Customer's payment(s) made payable to The Home Depot. Insurance proceeds will ❑ will not r be used to pay some or all of the total amount of sale. Description of Work to be Performed: Installation of Windows A more detailed description of the work to be performed is included in the section entitled Scope of Work which appears on page 3 of this Agreement. Anticipated Delivery Date / Installation Schedule Approximate Start Date: 04/13/2017 Approximate Finish Date: 05/11/2017 All dates are approximate and subject to change based on unforeseen events including inclement weather, permitting delays, and delays in confirming insurance coverage of Your claim for any repair, if applicable. Electronic Records Authorization: You are entitled to a paper copy of this Agreement if you choose. If you consent to an e-mailed copy, your consent applies to this Agreement and all subsequent documents and written communications related to this agreement. By contacting your Service Provider, you may update your email address, withdraw your consent, or obtain a paper copy of the Agreement or related documents at no charge. By providing your consent and verifying your email address above, you confirm that you have access to a computer that can receive and open emails and PDF documents. By initialing this paragraph, I consent to receive only electronic records related to this transaction. Initial Acce tance and Authorization: By signing below, you authorize Home Depot to (a) arrange for Service Provider to perform Installation and/or (b) order and arrange for the delivery of special order merchandise, including special order merchandise that may be custom made, as specified in this Agreement. Do not sign if blank or incomplete. (Service Provider's/permitting information may need to be provided to You later.) By signing, you acknowledge that you have read, understand, and accept this Agreement in its entirety, including the General Terms and Conditions and State Supplement, if any. You further acknowledge receiving a,complete copy of this Agreement. Keep it to protect your legal rights. I-, 02/16/2017 Date Date 02/16/2017 Date License number(s) held by or on behalf of the Home Depot: 2 Simonton Windows 0500 VartagePcint f,NP RV: _'OG"ie-Hunq Vinyl 1B" Glass Argon Lo:-t-E No Laminat&� Glass rlo Grads :.. FA `'entana ie dobie guillotha Vinilo 3.13 mm Vidno Argcn Lo'--E Sic ✓idrio ,aminadc Sic rejdas F v 33P-A-44-43008-00001 0i"- ` OFi ENERGY PERFORMANCE RATINGS EVALUACION DE RENDIMIENTO ENERGETICO — — — - ra-:o: ----- Solar Heat Gan .,oe Ticien. 0.29 1.65 0.26 ADDITIONAL PERFORMANCE RATINGS EVALUACION SUPLEMENTARIA DE RENDIPAIENTO V'si Ile Tans ,±ittance Air Leakage 0.50 <=0.3 <=1.5 unit cuai fres for ENERGY STAR3•regionss: NortnEm IND Rein F2:Glass ProScianlH-R35 DP:+35/-35 Tested Size: 52" K ! i" Ficn.-a Fr.xductApprovai FL516- Aoarirate Test S-aniaardi s;. ANSiiAAtdA)NYAND , 10111 ,.2-9 % Ar•14Ai,/JDMAiCS". 1?1/I.3.2!A440-0F .AAMA" 14DMAiCSA 10'1!.5 2/.A440-0°. A440: 1-09 Canadiar S:-,.p! S9672`.6111 5C27 .g !h-JA. obu- r 9333313 Keep tts labe: fcr p,ssibie ENERGY STAR ret,a:r;.. o .ea-n more visit <•hnr.eierg;star.gev Guarde esta etiqueta pesitles reembolso<_ ENERGY S. AR ` Par3 covocer mas acerca de esto visde The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 s ' www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Cont•actors/Electricians/PIumbers Name (Business/Organization/Individual): - - - �{'lY,6U 4-5- �l / r �i p'r 5KPhone # City/State/Zip: Are you an employer? Check the app`r 1. ❑ I am a employer with employees (full and/or part-time).* 2. ❑ I am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp, insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t -iate box: 4. ffi I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance) 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions 11. E] Plumbing repass or additions 12.❑Roteqp s13. `��i '� d a+NS *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and thea hire outside contractors must submit a new affidavit indicating such. TContractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that isproviding workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: `� ` !���t'�' Policy # or Self -ins. Lic. #: J� v`� `� '� !� Expiration Date: 3� / Job Site Address: > SIO CJ �— City/State/Zip: ��y Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify the pains and enalties of perjury that the information provided above is true and /correct �v�,� �.�L Date: Si nature: Official use only. Do not write in this area, to be completed by city or town official City or Town: Issuing Authority (circle one): 1. Board of Health 2. Building Department 6. Other Permit/License # 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector Contact Person: Phone `A� "® CERTIFICATE OF LIABILITY INSURANCE DATE (/2017 YYW) 02/172017 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 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 MARSH USA, INC.-NAME: TWO ALLIANCE CENTER CONTACT PHONE FAX c 'C' /c No): E-MAIL ADDRESS: 3560 LENOX ROAD, SUITE 2400 ATLANTA, GA 30326 INSURERS AFFORDING COVERAGE NAIC # INSURER A: Old Republic Insurance Co 24147 100492-HomeD-GAW'-17-18 INSURED THE HOME DEPOT, INC. INSURER B : Agri General Insurance Company 42757 INSURER C : New Hampshire Ins Co 23841 HOME DEPOT U.S.A., INC. 2455 PACES FERRY ROAD BUILDING C-20 INSURER D INSURER E: ATLANTA, GA 30339 INSURER F: MED EXP (Anyone person) $ EXCLUDED COVERAGES CERTIFICATE NUMBER: ATL -003741310-11 REVISION NUMBER:O 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 LTR TYPE OF INSURANCE ADDL J= SUBR wyn POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DD/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY MWZY 310022 03/01/2017 03/01/2018 EACH OCCURRENCE $ 9,000,000 CLAIMS -MADE M OCCUR DAMAGE"' occurrence) PREMISES Ea occurrence $ 1,000,000 MED EXP (Anyone person) $ EXCLUDED LIMITS OF POLICY XS PERSONAL & ADV INJURY $ 9,000,000 OF SIR: $1M PER OCC GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 9,000,000 X POLICY 1:1 JEST LOC PRODUCTS - COMP/OP AGG $ 9,000,000 $ OTHER: A AUTOMOBILE LIABILITY MWTB310021 03/01/2017 03/01/2018 COMBINED SINGLE LIMIT $ Ea accident 1,000,000 BODILY INJURY (Per person) $ X ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS SELF INSURED AUTO PHY DMG BODILY INJURY (Per accident) $ HIRED AUTOS NON -OWNED AUTOS PROPERTY DAMAGE $ Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED I I RETENTION$ $ B C C WORKERS COMPENSATION EMPLOYERS' LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory In NH) N / A WLR C49112300 (TN) WC 023102423 AK,NH,NJ,VT ( ) WC 023102424 (WI) 03/01/2017 03/01/2017 03/01/2017 03/01/2018 03/01/2018 03/01/2018 STATUTE __F X PEAT E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE- EA EMPLOYEE $ 1,000,000 Dyes, describe under D DESCRIPTION OF OPERATIONS below Continued on Additional Pae g E.L. DISEASE - POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required) I r= nvL.ur=r% TOWN OF NORTH ANDOVER 1600 OSGOOD ST. NORTH ANDOVER, MA 01845 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi Mukherjee i ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD r" AGENCY CUSTOMER ID: 100492 LOC #: Atlanta Alco/ ADDITIONAL REMARKS SCHEDULE v NAMED INSURED AGENCY .TOME DEPOT U.S.A., INC. MARSH USA, INC. DlBIA THE HOME DEPOT 2455 PACES FERRY ROAD POLICY NUMBER BUILDING C•20 ATLANTA, GA 30339 CARRIER ( NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance Workers Compensation Continued: Cartier. Indemnity insurance Company of North America Policy Number. WLR C49112294 (ALAR,FL,ID,IA,KS,KY,LA,MS,MO,NE,NM,ND,OK,SC,SD,WV,WY ) Effective Date: 0310112017 Expiration Date: 03101/2018 (EL) Limit: $1,000,000 Cartier: New Hampshire Insurance Company Polo Number. WC 023102422 (DC, DE,HI,IN,MD,MN,MT,NY,RI) Effective Date: 0310V2017 Expiration Date: 03101 /2018 (ELI limit: S1,000,000 ; Cartier. ACE American Insurance Company Pollcy Number. WCU C49112282 (QSI)(AZ, CA,IL,NC,CR,VA,WA ) Ef`ective Date: 0 3101 /2 01 7 Expiration Date: 03/01/2018 (EL) Limit' $1,000,000 SIR: 51,000,000 SIR for the states of AZ, CA,IL NC,OR,VA,WA Cartier: National Union Fre insurance Company Policy Number. XWC 6583144 (QSI) (CO,CT,GA,ME,MI,NV,OH,PA,UT) Effective Date: 0310112017 Expiration Date: 0310112018 (EL) limit: $1,000,000 51,000,000 SIR for the states of CO,ME,NV,MI, OH,PA, UT 5750,000 SIR for the state of GA 5354000 SIR for the state of CT Cartier. National Union Fire Insurance Company Policy Number. XWC 6583145 (OSI) (MA) Effective Date: 03/0112017 Expiration Date: 03101018 (EL) Limit $1,000,000 SIR: 8500,000 TX Employers XS Indemnity: Cantenlairics Union Insurance Company Policy Number. TNS 048613202 (TX) Effective Date: 0310112017 Expiration Date: 0310112018 (EL) Limit'. S10,000,000 SIR: 51,000,000 Page 2 of 3 ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ',lassachusetts Department of Public Safety r' Board of Suilding Regulations and Standards -..f License: CSSL-099699 ;onstructlon Supervisor Specia+ty ROBERT POCZOBUT _ I 172 WHALERS LANE SALEM MA 01970 ,orrr`,.ss c,�er 02/08/2018 ��e �Go�rrvrrarvroweal� a�✓�L�a>:uc�ccseG�t trice of Consumer Affairs & Business Regulation HOME IMPROVEMENT CONTRACTOR Registration 126893 Type: Expirat<sn g/38:y /20�Supplement Card THD AT HOME SERVICES INC . THE HOME DEPOT _AX HOME,SERVICES MARK NIADNA 2455 PACES FERRY ROAD_ , HSC - -- ATVANTA, GA 30339 Undersecretary