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HomeMy WebLinkAbout1000-35.-2-8 4 �
TOWN OF SOUTHOLD
r Rental Permit
4 �o� 0753
Owner 4545 Main Rd. Enterprises Inc.
Occupied as Single Family Dwelling
Located at 4545 Route 25 Greenport 35-2-8
Maximum Permitted Occupancy 3
Is in compliance with all of the provisions of the code of the Town of Southold, the laws and sanitary and housing regulations of
the County of Suffolk and by the laws adopted by the New York State Fire Prevention and Building Code Council. Expiration is
two (2)years from date of issue. The operator is responsible for arranging for the bi-annual inspection.
10/14/2022
SEoe t Official
This Notice must be posted by the main entrance at all times
L
S I `
r ocC Y V
` o
Town Hall Annex Telephone(631)765-1802
54375 Main Road cn Fax(631)765-9502
P.O.Box 1179 G y4
Southold,NY 11971-0959
`tel
BUILDING DEPARTMENT
TOWN OF SOUTHOLD
RENTAL PERMIT APPLICATION
Rental Permit Fee$200 (Application must be renewed every two years)
Section A.
Property Information:
Rental Property Address:
WSyS Q-6 9-T14 12i�, Gp > uPo�r o1�( 1 11t44
Tax Map Number: 1000 SECTION 1�3S -BLOCK 2 -LOT $ -
SECTION B.
OWNER INFORMATION:
Property Owner Name: . 4545 W niO IQp � !.> (�Pi2►s�-3 mac_
Property Owner Legal Address: Property Owner Mailing Address:
12 11 v 1M.A ►X3 � rZ ' Vo Sox 13
11934
Telephone Number (s): Daytime toil 417-6971Evening Emergency
Property Owner Email Address: Sdeoco tc— 1 do u cL
Page 1 of 5 O�
SO
Town Hall Annex Telephone(631)765-1802
54375 Main Road Fax(631)765-9502
CP
P.O.Box 11790
Southold,NY 11971-0959
c®UM`(
BUILDING DEPARTMENT
TOWN OF SOUTHOLD
Section C.
Authorized Agent Information:
Name of Authorized Agent of dwelling unit, if any: G f--1VN.0 y iL.i-Ya -Tiu
Address of Authorized Agent (no P.O. Boxes): 12a I a M Yn A>;1 o,0
Mailing Address of Authorized Agent: V0_ ?Z o r= 13 �4i �1 ig►216 6 �y . ►I �3�
Telephone Number (s): Daytimeb3l 07-o*7ZEvening Emergency
Email Address: �?r)40"V; ll cin I'% C----:) 1 cA o uA . `6 n^
Section D.
Managing Agent Information: �-
Name of Authorized Agent of dwelling unit, if any:
Address of Authorized Agent(no P.O. Boxes):.
Mailing Address of Authorized Agent:
Telephone Number(s): Daytime Evening Emergency
Email Address:
SECTION E. ki l Pr
SITE MANAGER INFORMATION: (required for rental properties containing 8 or more rental units)
Name of Managing Agent of dwelling unit, if any:
Address of Managing Agent (no P.O. Boxes):.
Page 2 of 5
J
� L
IN,Town Hall Annex t Telephone(631)765-1802
54375 Main Road Fax (631)765-9502
P.O.Box 1 179
Southold,NY 11971-09591 � �,{
mow , }'
BUILDING DEPARTMENT
TOWN OF SOUTHOLD
MailingAddress of Managing Agent:_ fN Vl ` I ° 0 ��� 1 -3 t�
g l; g
it
Telephone Number (s): Daytime l '7`Evening Emergency
C
Email Address: '(
SECTION F.
PROPERTY DESCRIPTION:
Number of Rental Dwelling Units on property: ojut L)s-E
For each Rental Dwelling Unit set forth the Rental Dwelling Unit identifier(for example,
Unit 1, Unit 2, Unit 3 or Apt A, B, Q the use of each room in the Rental Dwelling Unit
(for example, Kitchen, Bedroom 1, Bedroom 2, Living Room) and the dimensions of each
room.
For properties with multiple Rental Dwelling Units use "Rental Permit Application
Addendum."
Rental Dwelling Unit Identifier: �F
Requested Maximum number of persons allowed to occupy Dwelling Unit:
Number of rooms in Rental Dwelling Unit:
Use and Dimensions of each room in Rental Dwelling Unit:
Page 3 of 5
if S01/p
Town Hall Annex , Telephone(631)765-1802
54375 Main Road Fax(631)765-9502
P.O.Box 1179
Southold,NY 11971-0959
BUILDING DEPARTMENT
TOWN OF SOUTHOLD
SECTION G.
INSPECTION:
Pursuant to the Town Code of the Town of Southold Chapter 207 (Rental Properties), a safety
inspection by Code Enforcement Official is required. If the owner chooses not to have said
inspection performed by the Town, a certification from a licensed architect, a licensed
professional engineer or a home inspector who has a valid New York State Uniform Fire
Prevention Building Code Certification is required stating that the property which is the subject
of the rental permit application is in compliance with all of the provisions of the code,of the
Town of Southold,the laws and sanitary and housing regulations of the County of Suffolk and
by the laws adopted by the New York State Fire Prevention and Building Code Council.
I am requesting a fire safety inspection to be performed by a Code Enforcement Official
from the Town of Southold
❑ 1 am submitting a completed Town of Southold certification form from a licensed
architect or a licensed professional engineer.
SECTION H.
DECLARATION: Signature must be notarized and MUST be the owner of the dwelling unit.
STATE OF NEW YORK)
COUNTY OF SUFFOLK)
I &- Cn certify under penalty of perjury,the following:
1. 1 am the owner of the property identified in "Section A" of this application.
2. The property owner's legal address set forth in "Section B" of this application is my legal
address and I understand the Town will use the address for service pursuant to all
Page 4 of 5
p�S09 o
Town Hall Annexa i Telephone(631)765-1802
54375 Main Road Fax(631)765-9502
P.O.Box 1179 G �9Z
Southold,NY 11971-0959Qlc �
OUB, F
BUILDING DEPARTMENT
TOWN OF SOUTHOLD
applicable laws and rules. I further acknowledge that I will notify the Town of Southold
Building Department of any changes of address within five (5) days of any changes
thereto.
3. 1 have read and received a copy of Chapter 207 of the Code of the Town of Southold and
agreed to abide by the same.
4. 1 will notify the Town within five (5) business days as to any change to the information
regarding Authorized Agent, Managing Agent, or Site Manager.
z
Property Owner's Name: S R S
Property Owner's Si re:
Sworn to before me this_Taay of (��C)bPR ;20,Z�—
jhaLw ix i�lljvm
Official Notary 19blic Signature ao Original Notary Stamp
TRACEY L. DWYER
NOTARY PUBLIC,S-;'-ATE OF NEW YORK
NO.01 DW6306900
QUALIFIED IN SUFFOLK.COUNTY
COMMISSION EICPIRES,JUNE30,29,' (p
Page 5 of 5
.�L
oFsoulyo� mox �
# # TOWN OF SOUTHOMBaUILDING DEPT.
courm, 631-765-1802
INSPECTION
[ ] FOUNDATION 1ST [ ] ROUGH PLBG.
[ ] FOUNDATION 2ND [ ] INSULATION/CAULKING
[ ] FRAMING /STRAPPING [ ] INAL
[ ] FIREPLACE & CHIMNEY [ FIRE SAFETY INSPECTION
[ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION
[ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (F AL)
[ ] CODE VIOLATION [ ] PRE C/O [ RENTAL
REMARKS:
rze,
DATE 101 W")1% ' INSPECTOR
1 1 I I _I`fT f
rVIN
5 ' roba1_� �
� G �
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TOWN OF SOUTHOLD PROPERTY RECORD CARD
OWNER STREET VILLAGE DIST. _ SUB. LOT
tv
FORMER OWNER N E ACR.
1 /v,- f� " �* i s n rf fP{
! Fa ! p j a+j g`rPA /`f s— s `#s r.Yid �3Lt?� 1 1�3
_ S W CODE DATE OF CONSTRUCTION
J €a/��a 1' � e rig 1 til` �Lrr
LAND IMP. TOTAL DATE REM/JARKS (o
3�6 o ) //,P/Ij— - b 4:PL
= 51 a� 9 r 3401A stac t e-
0 0-1000 ,—} ''ifI `'���� "��� � (y
�2 7 t Wit`
Tillable FRONTAGE ON WATER
Woodland FRONTAGE ON ROADf
Meadowland ;: . DEPTH 4 �t
House Plot BULKHEAD
I Total
I
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i
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..........
,
s
M. Bldg. �. °; Foundation j ( Bath
f' a
Extension j I Basement ! Floors
Extension Ext. Wolfs
Interior Finish
Exter+s+t e r Fire Place i Heat
4 K 2-1:1 " ' Porch 1 i Roof Type
Porch Rooms 1 st Floor
Breezeway Patio I Rooms 2nd Floor
Garage j Driveway iDormer
Q B
TOWN OF SOUTHOLD PKOPERTY L__...�� ,.,-...D
OWNER STREET VILLAGE DISTRICT SUB. LOT -
FORMER OWNER N E ACREAGE
S W TYPE OF BUILDING
RES. j SEAS. VL FARM COMM IND CB. I MISC. Es Mkt. Value
LAND IMP. TOTAL DATE REMARKS ��
LF
s
n �
d
,.." •' 111
AGE ,- 4LD'ING CON 1144'°
NEW NORMAL BELOW ABOVE FRONTAGE ON WATER
Farm Acre Value Per Acre Value FRONTAGE ON ROAD
Tillable 1 I BULKHEAD
Tillable 2 }�— DOCK
r
Tillable 3
Woodland
Swampland _ __---- (�,
Brushland
House Plat
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Tota I
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Finished B SLAB Interior Finish
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TOVi ..)F SOUTHOLD
OFFICE OF BUILDING INSPECTOR
TOWN HALL
SOUTHOLD, NEW YOP.IC
CERTIFICATE OF OCCUPANCY
r NONCONFORMING PREMISES
TIIIS IS TO CERTIFY that the
/X/ Land Pre C.O. #- Z-16825
/ X/ Building(s) Date- April 28, 1988
C/ Use(s)
located at 4545 Main Road Greenport, New York
Street Hainlet
shown on County tax map as District 1000, Section 035 , Block 02 ,
Lot 08 , doesknot)conform to the present Building Zone Code of the
Town of Southold for the following reasons:
Non-Conforming Restaurant in the 'A' Zone. Insufficient total
Area.
On the basis of information presented to the Building Inspector's Office,
it has been determined that the above nonconforming %x/Land /F/Building(s)
r
/ /Use(s) existed on the effective date the present Building Zone Code of the
Town of Southold, and may be continued pursuant to and subject to the appli-
cable provisions of said Code.
IT IS FURTHER CERTIFIED that, based upon information presented to
the Building Inspector's Office, the occupancy and use for which this Certifi-
cate is issued is as follows: Property contains a one story restaurant with
exterior utilities i.e. refrigerators; fencing, blacktop driveway; a one story
cottage and all situated in 'A' ResidentiaAg
I ricultural zone with access to Main Rd.
a state wa ermi s c o6814 - ermit 11108Z C/O Z 6 13.
The Certificate is issued to ROBERT J. HEANEY
(owner, Yaxx)ee[7HC%SI@7=nb1
of the aforesaid building.
Suffolk County Department of IIealth Approval N/A
UNDERWRITERS CEIjTIFIC:A'I'•E NO. N-487107 & N-56574
NOTICI, IS HEREBY GI1rEN that the owner of the above premises I-IAS
NOT CONSENTED TO AN INSPECTION of the premises by the Building Inspec-
tor to determine if the premises comply with all applicable codes and ordin-
ances, other than the Building Gone Code, and therefore, no such inspection
has been conducted. This Certificate, therefore, does not, and is not intended
to certify that the premises comply with all other applicable codes and regula-
tions.
�.uildi- :.nS p ector
FORM NO.4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Town Clerk's Office
Southold, N.Y.
Certificate Of Occupancy
No. . . . 9963. . . . . . . . Date . . . . . . . . . .May 29. . . . . . . . .. . . . . . ., 19 80.
THIS CERTIFIES 4l�6,77he building . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Location of Property 47545Main Road. . , dreenpotct. N.Y.
House No. Street `• Hamlet
County Tax Map No. 1000 Section . . 035. . . . . .Block . .02 . . . . . . . . . .Lot . ,Oi�B
Subdivision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Filed Map No. . .Lot No.
1� requirements for residential and commercial�,b4lding
c rMs s{��ti to the �plicatia�.�a .8 1di .per t- ereto es�e��led-isrthirel ice-clad
April 23 . . , 19 57. pursuant to which Building Permit No. . 29963. . . . . . . . . . . . . .
9 80
dated . . . . .May .�. . . . . . . . . . . . . . . . . 19 . . ,was issued,and conforms to all of the requirements
of the applicable provisions of the law.The occupancy for which this certificate is issued is . A . . . . . .
One-F.aiatly Residence and A/Non conforming Commercial Restaurant
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
The certificate is issued to . . . . _Joan G. Tate
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(owner,I&M WYOMM'of the aforesaid building.
Suffolk County Department of Health Approval . . . NO Record .
UNDERWRITERS CERTIFICATE NO. . . . . . , , , , . NO Record
t
. . . . . , . . . . . . . . . . . .c..�—
Building Inspector
Rev 4/79
BUILDING DEPARTMENT
TOWN OF SOUTHOLD, N. Y.
HOUSING CODE INSPECTION REPORT
Location S�'S`- 545 Iy
Tuber & street) unici.pality)
Subdivision ' Map No. — Lot(s) --
Name of Owner(s) �Ti�)N C� • /.Lf��
Occupancy ��.3• f' - JO�J,(/ e NvE
t e Zowner )
Admitted by: lj�ff• 7 Accompanied by: me % ir-
Key available Suffolk Co. Tax No./y00 YJ-�S--a 2-•008'
Source of request'46l Date/yi4y Z/
DWELLING:
Type of construction_ GUddP /ei AW,E #stories O�( e
Foundation �.Clfyi /aC',� Cellar?,qi;L Crawl space -'L
Total rooms, lst. F141 zs• 2nd. Fl :=___3rd. Fl
Bathroom(s) OL.� �vLL�r Toilet room(s) —
Porch, type Deck, type Patio, type —
Breezeway Garage Utility room -
Type Heat jEQ�.yoeF`Warm Airg&a of/? .o Hotwater
Fireplace(sr-�----� No. Exits Tuwo Airconditioning�_
Domestic hotwater Type heaterr,�s f iirgl�
Other
ACCESSORY STRUCTURES:
Garage, type const. Storage, type const.
Swimming pool Guest, type const.
Other
VIOLATIONS: Housing Code, Chapter 52
Location Description Art. Sec.
r '
r
'07-
r- i - - a-60
-s ter- .Z A,
Remarks• -71 -
Inspected by: ate of Insp. Zy,!2�4
Time star
BUILDING DEPARTMENT
TOWN OF SOUTHOLD, N. Y.
HOUSING CODE INSPECTION REPORT
Location`�
--finumum er & s• ree unici a itTT
Subdivision Map No. Lot(s)
Name of Owner(s)
Occupancy,
— type owne
Admitted by: "/7 7A- 72:. Accompanied by:
Key available Suffolk Co. Tax No.&W--, S7-69-- yop
Source of request /1L• Date Z/�?d
Vf
Type of construction ,(�JodO r/�,s�-! _ #stories
Foundation. ldd=W77 r�k- Cellar-Z-9��Crawl space?�rz�L
Total rooms, 1st. F2:---4W--,2 2nd. Fl 3rd. F1 —
Bathroom(s) waive Toilet room(s) lcua �i�loLP i�,crJ
Porch, type Deck, type Patio, type
Breezeway Garage Utility room
Type Heat `darm Air a16 fi�Hotwater
Fireplace(s) No. Exits Airconditioning
Domestic hotwater 'r Type heater&
Other/Z&-4/--- sU p� _&e eS-!?
ACCESSORY STRUCTURES:
Garage, type const. Storage, type const.
Swimming pool Guest, type const.
Other
VIOLATIONS: Housing Code, Chapter 52
Location Description Art. Sec.
Remarks: p
Inspected by: to of Insp. Ar-rl Za a
Time start Z S',W end 3.'35 Rd '
FORM N064
TOWN OF SOUTHOLD
BUILDING DEPARTMINT
Town Clerk's Office
Southold, N. Y.
Certificate Of Occupancy
�555p October 9 73
No. . . . . . . . . Date . . . . . . . . . . . . . . .17. . . . . . . . . . . . ., 19. . . .
THIS CERTIFIES that the building located at . . Sunset .Way . . . . . . . . . . . . . Street
Map No. .90. . . . . . . . . Block No.P�. . . . . . . .Lot No. . 162. . . . . . . . . . . . . . . . . . . . . . . . . . . .
—IT onkorms substantially to the Application for Building Permit heretofore filed in this office
dated . . . . . . . .S!�pt!. 27 . . . ., 19.?�. pursuant to which Building Permit No. 55272 .
dated . . . . . . . . 3®p$!. 27 t. . . ., 19?�. ., was issued, and conforms to all of the require-
ments of the applicable provisions of the law. The occupancy for which this certificate is
issued is . . Private {aeoessory)storage build in&. . . . . . . . . . . . . . . . I . . . . . . . . . . .
The certificate is issued to . . . . John. p P. Gormley
(owner, lessee or tenant)
of the aforesaid building.
Suffolk County Department of Health Approval . .NR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
UNDERWRITERS CERTIFICATE No. .!T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
HOUSE NUMBER . . .44.0 . . . . . . . Street . . . . . . S mset way . . . . . . . .. . . . . . . . . . . . . . .
Southold
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . .: .
Building Inspect r
4
FORM NO.4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Office of the Building Inspector
Town Hall
Southold,N.Y.
Certificate Of Occupancy
No. . Z- 168,1.4 . . . . . . . Date . . . April 25: .1,988. . . . . . . . . . . .
THIS CERTIFIES that the building . . , , ,ADDITION TO RESTAURANT .
Location of Property 5 Main Road Greenport , N.Y. - '
House 454No. Street Hamlar
County Tax Map No. 1000 Section . . . 3 5. . . . . . .Block . . .2. . . . . . . . . . .Lot 8 . . . . . . . . . . . . . . .
Subdivision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Filed Map No. . . . . . . . .Lot No. . . . . . . . . . . . . .
conforms substantially to the Application for Building Permit heretofore filed in this office dated
June 4 19 8 0 10713 Z
pursuant to which Build . . . . . . . . .
. Building Permit No.
. . . . . . . . . . .
dated . , , June 9 1980
, . was issued,and conforms to all of the requirements
of the applicable provisions of the law. The occupancy for which this certificate is issued is . . . . . . . . .
ADDITION TO EXISTING RESTAURANT TO INCLUDE RESTROOM & STORAGE ROOM
The certificate is issued to . . , ,ROBERT J .HEANEY
(owner, @'v1x V1t010k. . . . . . . . . . . . . . . . . . . . .
of the aforesaid building.
Suffolk County Department of Health Approval . . . . . . . . N./A. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
UNDERWRITERS CERTIFICATE NO. . . . . . . . . . . . . . . . N 4 8 7.10.7. .:, July .2.5) . .1.9.8 0
PLUMBERS CERTIFICATION BATED: N/A
.msµ C'-2. . . . . . . . . . . . . . .
Building Inspector
flev.1/81
3 1
t
FORM NO.4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Office of the Building Inspector
Town Hall
Southold, N.Y.
Certificate Of Occupancy
No. . Z.; 16 8.1.3 . . . . . . . Date . .April 25,. 1988 . ..
THIS CERTIFIES that the building . . AD D I T I ON T.0 RES TAURA.N T
Location of Property ,4545 Main Road Greenport , .N.Y. . . .
House lUo. Street Hamlet
County Tax Map No. 1000 Section . . . . ?5. . . . . .Block . . .2 . . . . . . . . . . .Lot . . . .8. . . . . . . . . . . .
Subdivision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Filed Map No. . . . . . . . .Lot No. . . . . . . . . . . . . .
conforms substantially to the Application for Building Permit heretofore filed in this office dated
April ]0 , 1981. . . . pursua ] 1108 Z
. . . . . . . . . . . . . . . . . nt to which Building Permit No. . . . . . . . . . . . . . . . . . . . . .
dated , .A p r i l l 5 ,: 1 9 8 1
. . . . . . . . was issued, and conforms to all of the requirements
of the applicable provisions of the law. The occupancy for which this certificate is issued is . . . . . . . . .
ADDITION TO EXISTING RESTAURANT
The certificate is issued to . . . . . . , ROBERT J. H E AN E Y
. . . . . . . . . . . . . . . . . . . .
of the aforesaid building.
Suffolk County Department of Health Approval . . . . . . . . . .A. . . . . . _ . . .
UNDERWRITERS CERTIFICATE NO. . . . . . . . . . . . . . . .t?5 6 5.7 3 4. . . .J u n. ] 7.. .1.9 8 2. . . . . .
PLUMBERS CERTIFICATION DATED: N/A
Building Inspector
Rev. 1/81
FORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Office of the Building Inspector
Town Hall
Southold, N.Y.
CERTIFICATE OF OCCUPANCY
No: Z-33145 Date: 07/09/08
THIS CERTIFIES that the building ADDITION
Location of Property: 4545 MAIN RD GREENPORT
(HOUSE NO.) (STREET) (HAMLET)
County Tax Map No. 473889 Section 35 Block 2 Lot 8
Subdivision Filed Map No_ Lot No.
conforms substantially to the Application for Building Permit heretofore
filed in this office dated JUNE 25, 2008 pursuant to which
Building Permit No. 34012-Z dated JUNE 25, 2008
was issued, and conforms to all of the requirements of the applicable
provisions of the law. The occupancy for which this certificate is issued
is HANDICAP RAMP ADDITION TO AN EXISTING RESTAURANT AS APPLIED FOR.
The certificate is issued to ROBERT J HEANEY
(OWNER)
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF EWALTH APPROVAL N/A
HLECTRICAL CERTIFICATE NO. N/A
C
PLUMBERS CERTIFICATION DATED N/A
A thorized Signature
Rev. 1/81
CA Town of Southold 10/24/2017
P.O.Box 1179
53095 Main Rd
Southold,New York 11971
CERTIFICATE OF OCCUPANCY
No: 39311 Date: 10/24/2017
THIS CERTIFIES that the building AS BUILT ALTERATION
Location of Property: 4545 Route 25, Greenport
SCTM#: 473889 See/Block/Lot: 35.-2-8
Subdivision: Filed Map No. Lot No.
conforms substantially to the Application for Building Permit heretofore filed in this office dated
6/27/2017 pursuant to which Building Permit No. 41894 dated 8/21/2017
was issued,and conforms to all of the requirements of the applicable provisions of the law. The occupancy for
which this certificate is issued is:
"AS BUILT"MINOR ALTERATIONS INCLUDING NEW FIRE SUPPRESSION SYSTEM TO AN EXISTING
RESTAURANT AS APPLIED FOR
The certificate is issued to 4545 Main Rd Enterprs Inc
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL
ELECTRICAL CERTIFICATE NO.
PLUMBERS CERTIFICATION DATED
\W44
000
Signature