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Backup Documents 07/24/2012 Item #16C 7ORIGINAL DOCUMENTS CHECKLIST & ROU.TING S'�Ij� (� TO ACCOMPANY ALL ORIGINAL DOCUMENTS SENT T V t� THE BOARD OF COUNTY COMMISSIONERS OFFICE FOR SIGNATURE Print on pink paper. Attach to original document. Original documents should be hand delivered to the Board Office. The completed routing slip and original documents are to be forwarded to the Board Office only after the Board has taken action on the item.) ROUTING SLIP Complete routing lines # 1 through #4 as appropriate for additional signatures, dates, and/or information needed. If the document is already complete with the exception of the Chairman's signature, draw a line through routing lines # 1 through #4, complete the checklist, and forward to Sue Filson (line #5). Route to Addressee(s) (I ist in routing order) Office Initials Date 1. (I)'L -a (Initial) Applicable) 2. U Agenda Item Number 3. Approved by the BCC /Q�- 4. ( Type of Document R 5. Ian Mitchell, BCC Office Supervisor Board of County Commissioners Attached �12� I 6. Minutes and Records Clerk of Court's Office i26(R- PRIMARY CONTACT INFORMATION teas," (The primary contact is the holder of the original document pending BCC approval. Normally the primary contact is the person who created/prepared the executive summary. Primary contact information is needed in the event one of the addressees above, including Sue Filson, need to contact staff for additional or missing information. All original documents needing the BCC Chairman's signature are to be delivered to the BCC office only after the BCC has acted to approve the item.) Name of Primary Staff ) rnQl'�°iYL h?G Phone Number • 8 9a a Contact (I)'L -a (Initial) Applicable) Agenda Date Item was U Agenda Item Number ►-j Approved by the BCC /Q�- ( Type of Document R Number of Original resolutions, etc. signed by the County Attorney's Office and signature pages from Attached ��-°h� Documents Attached contracts, agreements, etc. that have been fully executed by all parties except the BCC INSTRUCTIONS & CHECKLIST is Forms/ County Forms/ BCC Forms/ Original Documents Routing Slip WWS Original 9.03.04, Revised 1.26.05, Revised 2.24.05, Revised 9.18.09 Initial the Yes column or mark "N /A" in the Not Applicable column, whichever is Yes N/A (Not appropriate. (Initial) Applicable) 1. Original document has been signed/initiated for legal sufficiency. (All documents to be signed by the Chairman, with the exception of most letters, must be reviewed and signed by the Office of the County Attorney. This includes signature pages from ordinances, resolutions, etc. signed by the County Attorney's Office and signature pages from contracts, agreements, etc. that have been fully executed by all parties except the BCC Chairman and Clerk to the Board and possibly State Officials.) 2. All handwritten strike - through and revisions have been initialed by the County - Attorney's �/H Office and all other parties except the BCC Chairman and the Clerk to the Board 3. The Chairman's signature line date has been entered as the date of BCC approval of the document or the final negotiated contract date whichever is applicable. 4. "Sign here" tabs are placed on the appropriate pages indicating where the Chairman's signature and initials are required. 5. In most cases (some contracts are an exception), the original document and this routing slip should be provided to Ian Mithchell in the BCC office within 24 hours of BCC approval. 1 ,I Some documents are time sensitive and require forwarding to Tallahassee within a certain time frame or the BCC's actions are nullified. Be aware of your deadlines! 6. The document was approved by the BCC on 7d 'rL (enter date) and all changes made during the meeting have been incorporated in the attached document. The County Attorney's Office has reviewed the changes, if applicable. is Forms/ County Forms/ BCC Forms/ Original Documents Routing Slip WWS Original 9.03.04, Revised 1.26.05, Revised 2.24.05, Revised 9.18.09 � Project: L.S. 300.06 Relocation — PUD Fence to Fence Group II 16 U Folio: 55051360003 PURCHASE AND SALE AGREEMENT THIS AGREEMENT is made and entered into by and between ADAM J. PISKADLO AND BARBARA K. PISKADLO, husband and wife, whose mailing address is 33 Natalie Court, Staten Island, New York 10304 (hereinafter referred to as "Seller "), and the BOARD OF COUNTY COMMISSIONERS OF COLLIER COUNTY, FLORIDA, AS THE GOVERNING BODY OF COLLIER COUNTY AND AS EX- OFFICIO THE GOVERNING BOARD OF THE COLLIER COUNTY WATER -SEWER DISTRICT, whose mailing address is 3335 Tamiami Trail East, Suite 101, Naples, Florida 34112 (hereinafter referred to as "Purchaser "). WITNESSETH WHEREAS, Seller is the owner of that certain real property (hereinafter referred to as "Property "), located in Collier County, State of Florida, and being more particularly described as follows: Lot 16, Block 20 of LELY GOLF ESTATES, ST. ANDREWS EAST, according to the Plat thereof as recorded in Plat Book 10, Page 98 of the Public Records of Collier County, Florida. WHEREAS, Purchaser is desirous of purchasing the Property, subject to the conditions and other agreements hereinafter set forth, and Seller is agreeable to such sale and to such conditions and agreements. NOW, THEREFORE, for and in consideration of the premises and the respective undertakings of the parties hereinafter set forth and the sum of Ten Dollars ($10.00), the receipt and sufficiency of which is hereby acknowledged, it is agreed as follows: AGREEMENT 1.01 In consideration of the purchase price and upon the terms and conditions hereinafter set forth, Seller shall sell to Purchaser and Purchaser shall purchase from Seller the Property. II. PAYMENT OF PURCHASE PRICE 2.01 The purchase price (the "Purchase Price ") for the Property shall be Sixty Seven Thousand Five Hundred and no /100 Dollars ($67,500.00) U.S. Currency payable at time of closing. This Agreement is subject to fund availability and future appropriation by the Board of County Commissioners. III. CLOSING 3.01 The Closing (THE "CLOSING DATE ", "DATE OF CLOSING ", OR "CLOSING ") of the transaction shall be held on or before ninety (90) days following execution of this Agreement by the Purchaser, unless extended by mutual written agreement of the parties hereto. The Closing shall be held at the Collier County Attorney's Office, Administration Building, 3299 Tamiami Trail East, Suite 800, Naples, Florida 34112 or at such other location as Purchaser may designate. The procedure to be followed by the parties in connection with the Closing shall be as follows: 3.011 Seller shall convey a marketable title free of any liens. Marketable title shall be determined according to applicable title standards adopted by the Florida Bar and in accordance with law. At the Closing, the Seller shall cause to be delivered to the Purchaser the items specified herein and the following documents and instruments duly executed and acknowledged, in recordable form: 3.0111 Warranty Deed in favor of Purchaser conveying title to the Property, free and clear of all liens and encumbrances other than: (a) The lien for current taxes and assessments. (b) Such other easements, restrictions or conditions of record. 3.0112 Combined Purchaser - Seller closing statement. 3.0113 A "Grantor's Non - Foreign, Tax Payer Identification & "GAP" Affidavit as required by Section 1445 of the Internal Revenue Code and as required by the title 16 C7 insurance underwriter in order to insure the "gap" and issue the policy contemplated by the title insurance commitment. 3.0114 A W -9 Form, "Request for Taxpayer Identification and Certification" as required by the Internal Revenue Service. 3.0115 If applicable, a Public Disclosure Affidavit in Accordance with Section 13.09 herein below. 3.012 At the Closing, the Purchaser, or its assignee, shall cause to be delivered to the Seller the following: 3.0121 A wire transfer or County Warrant in an amount equal to the Purchase Price. No funds shall be disbursed to Seller until the Title Company verifies that the state of the title to the Property has not changed adversely since the date of the last endorsement to the commitment, referenced in Section 4.011 thereto, and the Title Company is irrevocably committed to pay the Purchase Price to Seller and to issue the Owner's title policy to Purchaser in accordance with the commitment immediately after the recording of the deed. 3.0122 Funds payable to the Seller representing the cash payment due at Closing in accordance with Article III hereof, shall be subject to adjustment for prorations as hereinafter set forth. 3.02 Each party shall be responsible for payment of its own attorney's fees. Seller, at its sole cost and expense, shall pay at Closing all documentary stamp taxes due upon the recording of the Warranty Deed, in accordance with Chapter 201.01, Florida Statutes, and the cost of recording any instruments necessary to clear Seller's title to the Property. The cost of the Owner's Form B Title Policy, issued pursuant to the Commitment provided for in Section 4.011 below, shall be paid by Purchaser. The cost of the title commitment shall also be paid by Purchaser. 3.03 Purchaser shall pay for the cost of recording the Warranty Deed. Ad valorem and Non -Ad valorem taxes shall be prorated on a 365 -day calendar or fiscal year as applicable, based on the current year's tax. If Closing occurs at a date upon which the current year's tax rates are not fixed, taxes will be prorated based upon such prior year's tax rates. IV. REQUIREMENTS AND CONDITIONS 4.01 Upon execution of this Agreement by both parties or at such other time as specified within this Article, Purchaser and /or Seller, as the case may be, shall perform the following within the times stated, which shall be conditions precedent to the Closing: 4.011 Within fifteen (15) days after the date hereof, Purchaser shall obtain as evidence of title an ALTA Commitment for an Owner's Title Insurance Policy covering the Property, together with hard copies of all exceptions shown thereon. Purchaser shall have thirty (30) days, following receipt of the title insurance commitment, to notify Seller in writing of any objection to title other than liens evidencing monetary obligations, if any, which obligations shall be paid at Closing. If the title commitment contains exceptions that make the title unmarketable, Purchaser shall deliver to the Seller written notice of its intention to waive the applicable contingencies or to terminate this Agreement. 4.012 If Purchaser shall fail to advise the Seller in writing of any such objections in Seller's title in the manner herein required by this Agreement; the title shall be deemed acceptable. Upon notification of Purchaser's objection to title, Seller shall have thirty (30) days to remedy any defects in order to convey good and marketable title, except for liens or monetary obligations which will be satisfied at Closing. Seller, at its sole expense, shall use its best efforts to make such title good and marketable. In the event Seller is unable to cure said objections within said time period, Purchaser, by providing written notice to Seller within seven (7) days after expiration of said thirty (30) day period, may accept title as it then is, waiving any objection; or Purchaser may terminate the Agreement. A failure by Purchaser to give such written notice of termination within the time period provided herein shall be deemed an election by Purchaser to accept the exceptions to title as shown in the title commitment. 4.013 Seller agrees to furnish any existing surveys of the Property in Seller's possession to Purchaser within 10 (ten) days of the effective date of this Agreement. Purchaser shall have the option, at its own expense, to obtain a current survey of the Property prepared by a surveyor licensed by the State of Florida. No adjustments to 2 16 C7 the Purchase Price shall be made based upon any change to the total acreage referenced in Exhibit 'A" unless the difference in acreage revealed by survey exceeds 5% of the overall acreage. If the survey provided by Seller or obtained by Purchaser, as certified by a registered Florida surveyor, shows: (a) an encroachment onto the property; or (b) that an improvement located on the Property projects onto lands of others, or (c) lack of legal access to a public roadway, the Purchaser shall notify the Seller in writing of such encroachment, projection, or lack of legal access, and Seller shall have the option of curing said encroachment or projection, or obtaining legal access to the Property from a public roadway, within thirty (30) days of receipt of said written notice from Purchaser. Purchaser shall have thirty (30) days from the effective date of this Agreement to notify Seller of any such objections. Should Seller elect not to or be unable to remove the encroachment, projection, or provide legal access to the property within said thirty (30) day period, Purchaser, by providing written notice to Seller within seven (7) days after expiration of said thirty (30) day period, may accept the Property as it then is, waiving any objection to the encroachment, or projection, or lack of legal access, or Purchaser may terminate the Agreement. A failure by Purchaser to give such written notice of termination within the time period provided herein shall be deemed an election by Purchaser to accept the Property with the encroachment, or projection, or lack of legal access. V. INSPECTION PERIOD 5.01 Purchaser shall have sixty (60) days from the date of this Agreement, ( "Inspection Period "), to determine through appropriate investigation that: 1. Soil tests and engineering studies indicate that the Property can be developed without any abnormal demucking, soil stabilization or foundations. 2. There are no abnormal drainage or environmental requirements to the development of the Property. 3. The Property is in compliance with all applicable State and Federal environmental laws and the Property is free from any pollution or contamination. 4. Structures and facilities located on the property are sound and in good and safe operating contition. 5. The Property can be utilized for its intended purpose. 5.02 If Purchaser is not satisfied, for any reason whatsoever, with the results of any investigation, Purchaser shall deliver to Seller prior to the expiration of the Inspection Period, written notice of its intention to terminate this Agreement. If Purchaser fails to notify the Seller in writing of its specific objections as provided herein within the Inspection Period, it shall be deemed that the Purchaser is satisfied with the results of its investigations and the contingencies of this Article V shall be deemed waived. In the event Purchaser elects to terminate this Agreement because of the right of inspection, Purchaser shall deliver to Seller copies of all engineering reports, structural inspections and environmental and soil testing results commissioned by Purchaser with respect to the Property. 5.03 Purchaser and its agents, employees and servants shall, at their own risk and expense, have the right to go upon the Property for the purpose of surveying and conducting site analyses, soil borings and all other necessary investigation. Purchaser shall, in performing such tests and investigations, use due care not to damage property. Seller shall be notified by Purchaser no less than twenty -four (24) hours prior to any inspection of the Property. VII. POSSESSION 7.01 Purchaser shall be entitled to full possession of the Property at Closing. VIII. TERMINATION AND REMEDIES 8.01 If Seller shall have failed to perform any of the covenants and /or agreements contained herein which are to be performed by Seller, within ten (10) days of written notification of such failure, Purchaser may, at its option, terminate this Agreement by giving written notice of termination to Seller. Purchaser shall have the right to seek and enforce all rights and remedies available at law or in equity to a contract vendee, including the right to seek specific performance of this Agreement. 8.02 If Purchaser has not terminated this Agreement pursuant to any of the provisions authorizing such termination, and Purchaser fails to close the transaction contemplated hereby or otherwise fails to perform any of the terms, covenants and conditions of this Agreement as required on the part of Purchaser to be performed, provided Seller is not in default, then as Seller's sole remedy, Seller shall have the right to terminate and cancel 16 C7 14 this Agreement by giving written notice thereof to Purchaser, and neither party shall have any further liability or obligation to the other except as set forth in paragraph 12.01 (Real Estate Brokers) hereof. 8.03 The parties acknowledge that the remedies described herein and in the other provisions of this Agreement provide mutually satisfactory and sufficient remedies to each of the parties, and take into account the peculiar risks and expenses of each of the parties. IX. SELLER'S AND PURCHASER'S REPRESENTATIONS AND WARRANTIES 9.01 Seller and Purchaser represent and warrant the following: 9.011 Seller and Purchaser have full right and authority to enter into and to execute this Agreement and to undertake all actions and to perform all tasks required of each hereunder. Seller is not presently the subject of a pending, threatened or contemplated bankruptcy proceeding. 9.012 Seller has full right, power, and authority to own and operate the Property, and to execute, deliver, and perform its obligations under this Agreement and the instruments executed in connection herewith, and to consummate the transaction contemplated hereby. All necessary authorizations and approvals have been obtained authorizing Seller and Purchaser to execute and consummate the transaction contemplated hereby. At Closing, certified copies of such approvals shall be delivered to Purchaser and /or Seller, if necessary. 9.013 The warranties set forth in this paragraph shall be true on the date of this Agreement and as of the date of Closing. Purchaser's acceptance of a deed to the said Property shall not be deemed to be full performance and discharge of every agreement and obligation on the part of the Seller to be performed pursuant to the provisions of this Agreement. 9.014 Seller represents that it has no knowledge of any actions, suits, claims, proceedings, litigation or investigations pending or threatened against Seller, at law, equity or in arbitration before or by any federal, state, municipal or other governmental instrumentality that relate to this agreement or any other property that could, if continued, adversely affect Seller's ability to sell the Property to Purchaser according to the terms of this Agreement. 9.015 No party or person other than Purchaser has any right or option to acquire the Property or any portion thereof. 9.016 Until the date fixed for Closing, so long as this Agreement remains in force and effect, Seller shall not encumber or convey any portion of the Property or any rights therein, nor enter into any agreements granting any person or entity any rights with respect to the Property or any part thereof, without first obtaining the written consent of Purchaser to such conveyance, encumbrance, or agreement which consent may be withheld by Purchaser for any reason whatsoever. 9.017 To the best of Seller's knowledge, Seller represents that there are no incinerators, septic tanks or cesspools on the Property; all waste, if any, is discharged into a public sanitary sewer system; Seller represents that Seller has no knowledge that any pollutants are or have been discharged from the Property, directly or indirectly into any body of water. Seller represents the Property has not been used for the production, handling, storage, transportation, manufacture or disposal of hazardous or toxic substances or wastes, as such terms are defined in applicable laws and regulations, or any other activity that would have toxic results, and no such hazardous or toxic substances are currently used in connection with the operation of the Property, and there is no proceeding or inquiry by any authority with respect thereto. Seller represents that Seller has no knowledge that there is ground water contamination on the Property or potential of ground water contamination from neighboring properties. Seller represents that no storage tanks for gasoline or any other substances are or were located on the Property at any time during or prior to Seller's ownership thereof. Seller represents no part of the Property has been used as a sanitary landfill. 9.018 Seller has no knowledge that the Property and Seller's operations concerning the Property are in violation of any applicable Federal, State or local statute, law or regulation, or of any notice from any governmental body has been served upon Seller claiming any violation of any law, ordinance, code or regulation or requiring or calling attention to the need for any work, repairs, construction, alterations or installation on 4 16 V or in connection with the Property in order to comply with any laws, ordinances, codes or regulation with which Seller has not complied. 9.019 There are no unrecorded restrictions, easements or rights of way (other than existing zoning regulations) that restrict or affect the use of the Property, and there are no maintenance, construction, advertising, management, leasing, employment, service or other contracts affecting the Property. 9.020 Seller has no knowledge that there are any suits, actions or arbitration, bond issuances or proposals thereof, proposals for public improvement assessments, pay -back agreements, paving agreements, road expansion or improvement agreements, utility moratoriums, use moratoriums, improvement moratoriums, administrative or other proceedings or governmental investigations or requirements, formal or informal, existing or pending or threatened which affect the Property or which adversely affect Seller's ability to perform hereunder; nor is there any other charge or expense upon or related to the Property which has not been disclosed to Purchaser in writing prior to the effective date of this Agreement. 9.021 Seller acknowledges and agrees that Purchaser is entering into this Agreement based upon Seller's representations stated above and on the understanding that Seller will not cause the zoning or physical condition of the Property to change from its existing state on the effective date of this Agreement up to and including the Date of Closing. Therefore, Seller agrees not to enter into any contracts or agreements pertaining to or affecting the Property and not to do any act or omit to perform any act which would change the zoning or physical condition of the Property or the governmental ordinances or laws governing same. Seller also agrees to notify Purchaser promptly of any change in the facts contained in the foregoing representations and of any notice or proposed change in the zoning, or any other action or notice, that may be proposed or promulgated by any third parties or any governmental authorities having jurisdiction of the development of the property which may restrict or change any other condition of the Property. 9.022 At the Closing, Seller shall deliver to Purchaser a statement (hereinafter called the "Closing Representative Statement ") reasserting the foregoing representations as of the Date of Closing, which provisions shall survive the Closing. 9.023 Seller represents, warrants and agrees to indemnify, reimburse, defend and hold Purchaser harmless from any and all costs (including attorney's fees) asserted against, imposed on or incurred by Purchaser, directly or indirectly, pursuant to or in connection with the application of any Federal, State, local or common law relating to pollution or protection of the environment which shall be in accordance with, but not limited to, the Comprehensive Environmental Response, Compensation, and Liability Act of 1980, 42 U.S.C. Section 9601, et seq., ( "CERCLA" or "Superfund "), which was amended and upgraded by the Superfund Amendment and Reauthorization Act of 1986 ( "SARA "), including any amendments or successor in function to these acts. This provision, and the rights of Purchaser hereunder, shall survive Closing and are not deemed satisfied by conveyance of title. 9.024 Any loss and /or damage to the Property between the date of this Agreement and the date of Closing shall be Seller's sole risk and expense. 9.025 Neither party shall occupy or cause or permit others to occupy the Property prior to closing and funding, and will not occupy or cause or permit others to occupy the Property until after the closing. X. NOTICES 10.01 Any notice, request, demand, instruction or other communication to be given to either party hereunder shall be in writing, sent by facsimile with automated confirmation of transmission, or by registered, or certified mail, return receipt requested, postage prepaid, addressed as follows: If to Purchaser: Collier County Real Property Management 3335 Tamiami Trail East, Suite 101 Naples, Florida 34112 (239) 252 -8991 Phone (239) 252 -8876 Fax With a copy to: Office of the County Attorney 3299 Tamiami Trail East, Suite 800 Naples, Florida 34112 (239) 252 -8400 Phone (239) 774 -0225 Fax If to Seller: Mr. Adam J. and Mrs. Barbara K. Piskadlo 33 Natalie Court Staten Island, New York 10304 16 U7 With a copy to: Notice will be deemed received upon completion of facsimile transmission with automated confirmation, or after five (5) days of postmarking of Registered or Certified mail. 11.02 The addressees and numbers for the purpose of this Article may be changed by either party by giving written notice of such change to the other party in the manner provided herein. For the purpose of changing such addresses or addressees only, unless and until such written notice is received, the last addressee and respective address stated herein shall be deemed to continue in effect for all purposes. XII. REAL ESTATE BROKERS 12.01 Any and all brokerage commissions or fees shall be the sole responsibility of the Seller. Seller shall indemnify Purchaser and hold Purchaser harmless from and against any claim or liability for commission or fees to any broker or any other person or party claiming to have been engaged by Seller as a real estate broker, salesman or representative, in connection with this Agreement. XIII. MISCELLANEOUS 13.01 This Agreement may be executed in any manner of counterparts which together shall constitute the agreement of the parties. 13.02 This Agreement and the terms and provisions hereof shall be effective as of the date this Agreement is executed by both parties and shall inure to the benefit of and be binding upon the parties hereto and their respective heirs, executors, personal representatives, successors, successor trustees, and assignees whenever the context so requires or admits. 13.03 Any amendment to this Agreement shall not bind any of the parties hereof unless such amendment is in writing and executed and dated by Purchaser and Seller. Any amendment to this Agreement shall be binding upon Purchaser and Seller as soon as it has been executed by both parties. 13.04 Captions and section headings contained in this Agreement are for convenience and reference only; in no way do they define, describe, extend or limit the scope or intent of this Agreement or any provisions hereof. 13.05 All terms and words used in this Agreement, regardless of the number and gender in which used, shall be deemed to include any other gender or number as the context or the use thereof may require. 13.06 No waiver of any provision of this Agreement shall be effective unless it is in writing signed by the party against whom it is asserted, and any waiver of any provision of this Agreement shall be applicable only to the specific instance to which it is related and shall not be deemed to be a continuing or future waiver as to such provision or a waiver as to any other provision. 13.07 If any date specified in this Agreement falls on a Saturday, Sunday or legal holiday, then the date to which such reference is made shall be extended to the next succeeding business day. 13.08 Seller is aware of and understands that the 'offer" to purchase represented by this Agreement is subject to acceptance and approval by the Board of County Commissioners of Collier County, Florida. 13.09 If the Seller holds the Property in the form of a partnership, limited partnership, corporation, trust or any form of representative capacity whatsoever for others, Seller shall make a written public disclosure, according to Chapter 286, Florida Statutes, Under oath, of the name and address of every person having a beneficial interest in the Property before Property held in such capacity is conveyed to Collier County. If the corporation is registered with the Federal Securities Exchange Commission or registered pursuant to Chapter 517 Florida Statutes whose stock is for or sale to the general public, i �s6 exempt from the provisions of Chapter 286, Florida Statutes. 13.10 This Agreement is governed and construed in accordance with the laws of the State of Florida. XIV. ENTIRE AGREEMENT 14.01 This Agreement and the exhibits attached hereto contain the entire agreement between the parties, and no promise, representation, warranty or covenant not included in this Agreement or any such referenced agreements has been or is being relied upon by either party. No modification or amendment of this Agreement shall be of any force or effect unless made in writing and executed and dated by both Purchaser and Seller. Time is of the essence of this Agreement. IN WITNESS WHEREOF, the parties hereto have signed below. Dated Acquisition Approved by BCC: U�Lf- I,)— c" AS TO PURCHASER: DATED: 7 Y !.2, ATTEST: DWIGHT E. BROCK, Clerk 8� 4 , BOARD OF COUNTY COM91SS1ONERS OF COLLIER COUNTY, FitkRIDA AS THE GOVERNING BODY W- :- rOLL1ER 4 ; COUNTY AND AS EX =OFFS THl GOVERNING BOARD OF Tl3E %C,OLUER2" COUNTY WATER -SEWER Df.'iTitICT ti i B luj_ . • y. ':�D u Clerk Fred W. Coyle, Chairman y AS,TO �§tLLIA Witness (Signature) Name: Fi« I�o�r•( A �;Tdro (Pr r t e) Adam C/1 33 Na Stater i s (Signature) Name: 164RjAfA S•Cif,EUc (Print or type) Witness (S' na Name: Witness LSignature) Name: f el ChAJ0D /�.. �%�-w (Print or type) App r ed as to form and le ency Jeff k. Wr ght, Assistant County Attorney It E d, New York 10304 2— Barbara K. Piskadlo 33 Natalie Court Staten Island, New York 10304