HomeMy WebLinkAboutL 12769 P 568 lllllll Illi full Ill!!iflil VIII VIII VIII VIII Illi Illi
I Illlil Illlf VIII IIII IIII
SUFFOLK COUNTY CLERK
RECORDS OFFICE
RECORDING PAGE
Type of Instrument: DEED Recorded: 04/04/2014
Number of Pages: 8 At: 01:30:35 PM
Receipt Number : 14-0043427
TRANSFER TAX NUMBER: 13-22812 LIBER: D00012769
PAGE: 568
District: Section: Block: Lot:
1000 079.00 07.00 044.001
EXAMINED AND CHARGED AS FOLLOWS
Deed Amount: $125, 000.00
Received the Following Fees For Above Instrument
Exempt Exempt
Page/Filing $40.00 NO Handling $20.00 NO
COE $5.00 NO NYS SRCHG $15.00 NO
EA-CTY $5.00 NO EA-STATE $250. 00 NO
TP-584 $5.00 NO Notation $0.00 NO
Cert.Copies $5.20 NO RPT $60.00 NO
Transfer tax $500.00 NO Comm.Pres $1, 000.00 NO
Fees Paid $1, 905.20
TRANSFER TAX NUMBER: 13-22812
THIS PAGE IS A PART OF THE INSTRUMENT
THIS IS NOT A BILL
JUDITH A. PASCALE
County Clerk, Suffolk County
as
Nuinber of pages RECORDED
2014 Apr 04 01:30:35 PM
JUDITH A. PASCALE
CLERK OF
This document will be public SUFFOLK COUNTY
record. Please remove all L D00012769
P 568
DT# 13-22812
Stamp Recording/Filing Stamps
Page/Filing Fee Mortgage Amt.
1. Basic Tax
Handling 20. 00 2. Additional Tax
TP-584 Sub Total
Notation Spec./Assit.
or
EA-52 17(County) Sub Total Spec./Add.
EA-5217(State) TOT.MTG.TAX
R.P.T.S.A. Dual Town—Dual County—
Held for Appointment
Comm.of Ed. 5. 00 Transfer Tax 570,�)
Mansion ansion Tax
Certified Cop The property covered by this mortgage is
or will be improved by a one or two
NYS Surcharge 15. 00 33 family dwelling only.
Sub Total YES or NO
Other — Grand Total
s If NO,see appropriate tax clause on
page#—of this instrument' I
3 /P-io /y
4 1 Dist. r000
14008488 1.000 07000 0700 044001 5 Community Preservation Fund
Real Property, P S Consideration Amount$ Via,ct
Tax Service R POL A
Agency 04-APR-1 CPF Tax
Verification -- ----- -----J1 Improved
6 Satisfactions/Discharges/Releases List Property Owners Mailing Address
RECORD&RETURN TO: Vacant Land
C'4foojo' TD
TD
11-7V-7 TD
Mail to:Judith A. Pascale, Suffolk County Clerk 7 Title Company Information
310 Center Drive, Riverhead, NY 11901 Co.Name 7-/7Z-,O-
www.suffolkcountyny.gov/clerk Title# 5911
8 ' Suffolk County Recording & Endorsement Page
This page forms part of the attached -W) made by:
(SPECIFY TYPE OF INSTRUMENT)
1.4 ovL-4 The premises herein is situated in
SUFFOLK COUNTY,NEW YORK.
TO r In the TOWN of EG L)-r-A 0 L b
PE7-,--A 4- �>,p5 In the VILLAGE
or HAMLET of
BOXES 6 THRU 8 MUST BE TYPED OR PRINTED IN BLACK INK ONLY PRIOR TO RECORDING OR FILING.
12.0104,,10108kk (over)
NY 005-Bargain and Sale Deed with Covenant against Grantor's Acts Individual or Corporation(Single Sheet)(NYBTU 8002)
CONSULT YOUR LAWYER BEFORE SIGNING THIS INSTRUNIEN'Y-THIS INSTRUMENT SHOULD BE USED BY LAWYERS ONLY
qrc 111
THIS INDENTURE,made the 1� day of 3aw4at3L,in the year 2014
BETWEEN
STANLEY G.BROWN,residing at; 15075 New Suffolk Avenue,New Suffolk,New York 11956.
HIS -,'AO
party of the first part,and PETER SOLOWSKY and DORIS SOLOWSKYresiding at; 1930 Leeward Drive,Southold,
New York 11971.
party of the second part,
r3 tr
WITNESSETH,that the party of the first part,in consideration of Ten Dollars and other valuable consideration paid by
the party of the second part,does hereby grant and release unto the party of the second part,the heirs or successors and
assigns of the party of the second part forever,
ALL that certain plot,piece or parcel of land,with the buildings and improvements thereon erected,situate,lying and
being imlin at Bayview,in the Town of Southold,County of Suffolk and State of New York,known and designated as
the Southeasterly 1/2 of Lot No.49 on a certain map entitled,"Leeward Acres at Bayview",filed in the Office of the
Clerk of the County of Suffolk on June 4,1971 as Map No.5599,bounded and descrived as follows:
BEGINNING at a point on the Southwesterly side of Leeward Drive where same is intersected by the division line
6 11 between Lots 49 and 48 on the aforesaid map;
RUNNING THENCE South 37 degrees 30 minutes 30 seconds West 471.13 feet;
RUNNING THENCE North 56 degrees 50 minutes 30 seconds West 50.145 feet;
RUNNING THENCE North 37 degrees 30 minutes 30 seconds West 474.94 feet to the Southwesterly side of Leeward
Drive;
RUNNING THENCE along the Southwesterly side of Leeward Drive,South 52 degrees 29 minutes 30 seconds East
50.00 feet to the point or place of BEGINNING.
Said premises known as 1820 Leeward Drive,Southold,New York.
This conveyance involves a Lot Line Modification,approved by the Southold Town Planning Board by resolution
dated ,?ltQjj+
Attached hereto as Schedule B is a map showing a Lot Line Modification.
TOGETHER with all right, title and interest, if any,of the party of the first part of, in and to any streets and roads
abutting the above-described premises to the center lines thereof;TOGETHER with the appurtenances and all the estate
and rights of the party of the first part in and to said premises;TO HAVE AND TO HOLD the premises herein granted
unto the party of the second part,the heirs or successors and assigns of the party of the second part forever.
AND the party of the first part covenants that the party of the first part has not done or suffered anything whereby the
said premises have been encumbered in any way whatever,except as aforesaid.
AND the party of the first part,in compliance with Section 13 of the Lien Law,covenants that the party of the first part
will receive the consideration for this conveyance and will hold the right to receive such consideration as a trust fund to
be applied first for the purpose of paying the cost of the improvement and will apply the same first to the payment of the
cost of the improvement before using any part of the total of the same for any other purpose.
The word"parry"shall be construed as if it read"parties"whenever the sense of this indenture so requires.
IN WITNESS WHEREOF,the party of the first part has duly executed this deed the day and year first above written.
IN PRESENCE OF: �
V STANLEY G.BROWN
r -
MAULING ADDRESS:
PLANNING BOARD HERS �tf so P.O.Box 1179
DONALD J.WILCENSKI �4� f/f Southold,NY 11971
Chair �7
OFFICE LOCATION:
VRLLIAM J.CREMER.S 40
Town Hall Annear.
PIERCE RAFFERTY 54375 State Route 25
JAMS H.RICH IIIA �� (cor.Main Rd.&Youngs Ave.)
MARTIN H.SIDOR ��"�uun� ' Southold,NY
u� Telephone:631765-1938
Fam 631 765-3236
PLANK G BOARD OFFICE
TOWN OF SOUTHOLD
State Environmental Quality Review
NEGATIVE DECLARATION
Notice of Determination Non-Significant
March 10, 2014
This notice is issued_pursuant to Part 617 of the implementing regulations pertaining to
Article 8 (State Environmental Quality Review Act) of the Environmental Law.
The Southold Town Planning Board, as lead agency, has determined that the proposed
action described below wily not have a significant effect on the environment and a Draft
Environmental Impact Statement will not be prepared.
Name of Action: Proposed Lot Line Change for Rzeszut, Solowsky& Brown
SCTM#: SCTMs#1000-79-7-44.3, 44 &45
Location: on the swlslo Leeward Drive, approximately 945' n/o Bayview Road, in
Southold
SEAR Status: Type I ( )
Unlisted (X)
Conditioned Negative Declaration: Yes ( )
No (X)
Description of Action: This proposed Lot Line Modification transfers 1.1 acres from
SCTM#1000-79-7-44 to SCTM#1000-79-7-43.3 and SCTM#1000-79-7-45.
SCTM#1000-79-7-44 will decrease in size from 1.1 acres to 0.00 acres; SCTM#1000-
79-7-44.3 will increase from 1.2 acres to 1.8 acres, and SCTM#1000-79-7-45 will
increase from 1.1 acres to 1.6 acres.
Reasons Supporting This Determination:
An Environmental Assessment Form has been submitted and reviewed and it was
determined that no significant adverse effects to the environment were likely to occur
should the project be implemented as planned.
Negative Declaration Page Two March 10, 2014
The determination was based upon the following:
This Lot Line Modification will not have any adverse impacts on the surrounding
neighborhood or adjacent properties. No new lots will be created, and no increase in
developmeht is expected as a result due to the configuration of the land transfer. Thus the
following can be said of this action:
Therefore, the proposed application will have no bearing upon Article VI of the Suffolk
County Sanitary Code and will, therefore, conform to Article VI of the Suffolk County
Sanitary Code and will not be expected to adversely affect groundwater quality.
1. No substantial adverse change in existing air quality, ground or surface water quality
or quantity, traffic or noise levels, no substantial increase in solid waste production,
potential of erosion, flooding, leaching or drainage problems will occur as a result of
this action.
2. No significant removal or destruction of large quantities of vegetation or fauna, no
substantial interference with the movement of any resident or migratory fish or
wildlife species, no significant impacts on a significant habitat area, no substantial
adverse impacts on a threatened or endangered species of animal or plant or the
habitat of such a species, and no other significant adverse impacts to natural
resources MI occur as a result of this lot line change.
3. The proposed action is not in a material conflict with a community's current plans
or goals as officially approved or adopted.
4. The proposed action will not significantly impair the character or quality of
important historical, archae6logical, architectural,-or aesthetic resources or of
existing community or neighborhood character.
5. No major change in the use of either the quantity or type of energy will occur.
Each existing improved lot will continue to have only one pre-existing single
family dwelling on each.
6. No creation of a hazard to human health will occur as a result of this lot line
change.
7. The proposed action will not cause a substantial change in the use, or intensity of
use, of land including agricultural, open space or recreational resources, or in its
capacity to support existing uses.
8. Based upon such, no significant adverse impacts to the environment are
expected to occur should the project be implemented as planned.
For Further Information:
Contact Person: Alyxandra Sabatino, Planner
Address: Southold Town Planning Board
Telephone Number: (631) 765-1938
MAILING ADDRESS:
PLANNING BOARD MEMBERS P.O.Box 1179
V
DONALD J.WILCENSKI V Southold,NY 119?I
1�f OFFICE LOCATION:
RrII,I;lAM J.CREMERS �, Town Hall Annex
' PIERCE MA.V='TY RICH Ill �Q 54375 State Route 25
JAMES H. ll co y, (cor.Main Rd.&Youngs Ave.)
s Southold,NY
Telephone:631765-1938
Fax:631766-3136
PLANNING BOARD OFFICE
TOWN OF SOUTHOLD
March 11, 2014
Mr. Joseph Rzeszut
251 Beebe Road
Mineola, New York 11501
Re: Final Approval: Proposed Lot Line Modification for Rzeszut, Solowsky& Brown
Located at 1820 Leeward Drive, Southold
SCTM#1000-79-7-43.3, 44 &45 Zoning District: R-40
Dear Mr. Rzeszut: ,
The Southold Town Planning Board adopted the following resolutions at a meeting held on
Monday, March 10, 2014:
WHEREAS, this proposed Lot Line Modification transfers 1.1 acres from SCTM#1000-79-7-
44 to SCTM#1000-79-7-43.3 and SCTM#1000-79-7-45. SCTM#1000-79-7-14 will decrease
in size from 1.1 acres to 0.00 acres; SCTM#1000-79-7-44.3 will increase from 1.2 acres to
1.8 acres, and SCTM#1000-79-7-45 will increase from 1.1 acres to 1.6 acres; and
WHEREAS, on December 9, 2013, a Lot Line Modification Application was submitted; and
WHEREAS, on December 16, 2013, the applicant submitted 6 maps of the proposed.Lot Line
Modification; and
WHEREAS, on January 6, 2014, at their Work Session,the Planning Board reviewed the
application and found it complete with items to be submitted immediately; and
WHEREAS, on January 7, 2094, referrals were sent out to all applicable agencies; and
WHEREAS, on January 13, 2014, the Planning Board set the public hearing; and
WHEREAS, on January 16, 2014, the Southold Fire District responded to the referral stating
that there is adequate fire protection for this property; and
WHEREAS, on January 17, 2014, the applicant submitted draft deeds; acid
WHEREAS, on January 24, 2014,the Local Waterfront Revitalization Coordinator found the
application exempt from the Local Waterfront Revitalization Program; and
Rzeszut, Solowsky & Brown Page Two March 11, 2014
WHEREAS, on February 10, 2014, the Planning Board held and closed the public hearing;
and
WHEREAS, on February 11, 2014, the Suffolk County Planning Commission responded to
the referral stating that"the application is considered a matter of local determination"; and
WHEREAS, on February 26, 2014, at their Work Session, the Planning Board reviewed and
accepted all referrals received from agencies and the submitted draft deeds; and
WHEREAS, the Southold Town Planning Board, pursuant to Town Code §240-56, Waivers of
Certain Provisions may waive certain elements of the subdivision review if in As judgment
they are not requisite in the interest of the public health, safety and general welfare. After
reviewing the information submitted for this application, the Planning Board has determined
that it is eligible for a waiver of the Environmental Resources Site Analysis Plan (ERSAP), the
Primary and Secondary Conservation Area Plan, the public hearing,.and the Sketch Plan and
Preliminary Plat steps of the subdivision process for the following reasons:
1. No new lots are being created;
2. No changes will occur as a result of this lot line change that would adversely affect the
character of the neighborhood; and
WHEREAS, the Planning Board performed an uncoordinated review of this Unlisted Action
pursuant to 6 NYCRR Part 617, Section 617.7 of the State Environmental Quality Review Act
(SEORA); and
WHEREAS, pursuant to the Lot Line Modification Policy set by the Planning Board in
February 2011, this application is eligible for decision from the Planning Board prior to
receiving approval by the Suffolk County Department of Health Services (SCDHS) as it meets
the following criterion set forth in that policy:
• where no new development potential will be created in the parcel to which the land is
transferred; and
WHEREAS, on February 26, 2014, at their Work-Session, the Planning Board determined
that the proposed action meets all the necessary requirements of Town Code §240-57 for a
Lot Line Modification; be it therefore
RESOLVED, that the Planning Board, pursuant to SEQRA, hereby makes a determination of
non-significance for the proposed Lot Line Modification and grants a Negative Declaration;
and be it further
RESOLVED, that the Planning Board hereby waives the requirements of Town Code §240 to
submit the ERSAP, Primary and Secondary Conserv6tion Plans, Sketch Plan and Preliminary
Plat steps; and be it further
RESOLVED, that the Planning Board hereby waives the requirement for SCDHS approval
prior to Planning Board approval of this lot line modification; and be it further
Z,
Rzeszut, Salowsky,& Brown Page Three March 11, 2014
RESOLVED, that the Southold Town Planning Board grants Final Approval on the maps
entitled "Re-Subdivision Map Peter Solowsky and Joseph J. Rzeszut, Jr.", prepared by
Howard Young, Land Surveyor, dated December 3, 2013, and authorizes the Chairman to
endorse the map.
Please submit a copy of the recorded deed to the Southold Town Planning Department
within 632 days of the date of Final Approval, or such approval shall expire and be null
and void.
Please Note: The Southold Town Planning Board, in waiving the requirement for
SCDHS approval prior to their own approval, is simply waiving a technical requirement
of Final Plat Approval under the Town Code and makes no representations as to
whether SCDHS approval is required. SCDHS approval of this Lot Line Change may be
necessary to be In compliance with the Suffolk County Sanitary Code and to be eligible
for future construction or renovations.
If you have any.questions regarding the above, please contact this office.
Very truly yours,
Donald J. Wilcenski
Chairman
Encl. Endorsed Final Map
Negative Declaration
cc: Assessors
I understand that Southold Town Planning Board approval of this Lot Line Modification
does not grant, guarantee or waive an approval, if required, from the Suffolk County
Department of Health Services (SCDHS). I understand that I will need to apply
separately to the SCDHS for any applicable approvals.
c!WnqOre of 4_ppl r`Agent Print Name
IISEACKNOWLEDGMENTFORMBELOWWITHINNEWYORKSTATEONLK USEACKNOWLEDGMENTFORMRELOWWITHINNEWYORKSTATEONLY:
State of New York,County of SUFFOLK)ss.: State of New York,County of )ss.:
On the d4 day of 0�7 in the year 0,t t( On the day of in the year
before me, the undersigned, personally appeared STANLEY G. before me,the undersigned,personally appeared personally
BROWN,personally known to me or proved to me on the basis of known to me or proved to me on the basis of satisfactory evidence
satisfactory evidence to be the individual(s)whose name(s)is(are) to be the individual(s) whose name(s) is (are) subscribed to the
subscribed to the within instrument and acknowledged to me that within instrument and acknowledged to me that he/she/they
he/she/they executed the same in his/her/their capacity(ies),and that executed the same in his/her/their capacity(ics), and that by
by his/her/their signature(s)on the instrument,the individual(s),or his/her/their signature(s)on the instrument,the individual(s),or the
the person upon behalf of which the individual(s)acted, executed person upon behalf of which the individual(s)acted, executed the
the' strument instrument.
KATHRYN GAETA
Notary Public,State of New York
No.OIGA6066891
Qualified in Nassau County
Commission Expires November 26,20
ACKNOWLEDGMENTFORMFORUSEWITHINNEWYORKSTATEONLY ACKNOWLEDGMENTFORMFORUSEOUTSIDENEWYORKSTATEONLY.
(New York Subscribing Witness Acknowledgment Certificate) (Out ofStafe or Foreign General Acknowledgment Certificate)
State of New York,County of )SS.: )Ss.:
On the day of In the year (Compl¢te venue wit State,Country,Province ar Municipality)
before me,the undersigned,personally appeared On the day of in the year
the subscribing witness to the foregoing instrument,with whom I before me,the undersigned,personally appeared
am personally acquainted, who, being by me duly sworn, did personally known to me or proved to me on the basis of satisfactory
depose and say that he/she/they reside(s)in evidence to be the individual(s)whose name(s)is(are)subscribed
to the within instrument and acknowledged to me that he/she/they
(ifthe place ofresidence is in a city,include the street and street number,if executed the same in his/her/their eapacity(ies), that by his/her/
any,thereof};that he/she/they know(s)to be the individual described their signature(s)on the instrument,the individual(s),or the person
in and who executed the foregoing instrument;that said subscribing upon behalf of which the individual(s) acted, executed the
witness was present and saw said instrument.
execute the same;and that said witness at the same time subscribed
his/her/their name(s)as a witness thereto.
BARGAIN&SALE DEED
WITH COVENANTS AGAINST OKANTOWS ACTS
a DISTRICT 100
TITLE NO. NT'699/l SECTION 079.00
STANLEY G.BROWN BLOCK 07.00
LOT-944IM plo YY
COUNCYORTOWN SUFFOLK
TO
PETER SOLOWSKY and DORIS SOLOWSKY
RECORDEDATREQUESTOF
Fidelity National Title Insurance Company
RETURNBYAWL 70
FIDELITY NATIONAL TITLE
INSURANCE COMPANY IBM A CIRINO ESQ.
1NIX R"AAM 1928 35 PINELAWN ROAD,STE 218E
MELVIILE,NEW YORK 11747
i yr, re-,G Fidelity '
MsrnM N-Ymk SaW 1—d71drAssodad"
0 .
0
a
u.
0
u.
w
v
a
a
N
2
PLEASE TYPE OR PRESS FIRMLY WHEN WRITING ON FORM
INSTRUCTIONS(RP-52174NS):terww.orps.state.rty.us
FOR COUNTY USE ONLY �f Q Q/�
C1.SY81S Code ) ` , 3, d , d "i I New York State DeparDn9nt of
Taxation and Finance
C2.Data Dead Recorded / / Office of Reay Property Tax Services
(/�y " .56Yr RP-5217
C3.Book I I C4.PagelLq
I Real Property Transfer Report(8110)
PROPERTY INFORMATION
1.Property I 1820 I Leeward Drive
Location--1--.. -.1
1 Southold t ) 119711 I
�rrsa"- vaLAeE IPCODE
Z.Buyer �SGI.O.waM.
Name inrxa r coo I MRSPaer I
I Solowsky I Doris
�TlBtlasrlarary
3.Tax Indicate where future Tax Bills are to be sem
Baling if other then buyer address(at bottom of form) �,�K.1 1 FIRSI7aWk --"
Address
STREET NUMIEN AND
U I yam- ISrAW bpo= I
4.Indicate the number,of Assessment ❑ (Only a Part of a Parcel)Check as it"appy:
Rall parcels transferredg M d on the dead l_,_,_i J Parcels OR Part of a Parcel ❑
4A.Planning Board with Subdivision Authority Exists
5.Deed 48.Subdivision Approval was Required for Transfer
Property I 1 x11 I ORI . a I 4C.Panel Approved for Subdivision with Map Provided
SW
9.Sauer I Jlro�*r I Stanley G.r I
Name r r FIRST RAME
DIe,NAME I rA4i I 1781 RATA.
7.Check the hos below which most accurately describes the use of the property at as time of sale: Check the boxes below as they apply:
8.Ownership Type is Condominium
A Ono Family Rosidonaal Agricultural I Community Service 9.Now Construction on Vacant Land
11 2 or 3 Family Residential F Commercial J Industrial 10A.Property Located within an Agricultural District 0
C Residential Vacant Land G Apartment K Public Service 106.Buyer received a disclosure notice Indicating I-I
D Noo-Rosidentlel Vacant Land H Entertainment I Amusement L Forest that the property Is in an Agricultural District
SALE INFORMATION 11 Check one or mon of these conditions as applicable to transfer.
11.sale contract Dale I 11 / 07 / 2013 a A sale Between Relatives or Former Relatives
Ga, 'car H Sale Between Related Companies or Partners in Business
C One of the Buyers is also a Seller
12.Data of Sale I Transfer I 03 / 26 / 2014 I D Buyer or Seller is Government Agency or Lending Inslaullo n
rmr E Deed Type not Warranty or Bargain and Sale(Specify Below)
F Sale of Fractional or Less Than Fee interest(Specify Below)
(i Significant Change in Property Betwacn Taxable Status and Sale Dates
13.Fut Sala Price
I 1 , 2 , 5. 0. 0. 0 e 0 0 1 H Sale of Business is Included in Sale Pike
(Fug Sale Price is the IONI amount paid for the property indud'ag personal property. 1 Other Unusual FactpS Affecting Sale Price(Specify Below)
This payment may be in the form of cash,other property or goods,or the assumption of J Nona
mortgages or other obtpebons.) Please round to the neerosl whob closer amount.
14.Indicate the value of personal I 0 - 0.0 I
property Included in the sale -�----y
ASSESSMENT INFORMATION Data should reflect the latest Final Assessment Rall and Tax Bill
18.Year h I Assessment taken
Raiken hem l 1. 3 11T Total Assessed Value(of all parcels In bans%ra ;_ T 0 .0 1
which Information bkon
18.Property class 1 3, 1.1 I-I_J 19.SchodDistrict Name I Southold #473805 _ I
20.Tax Map MoMMails)I Roll Idsntl0er(s)(It mon than four,attach shoot with eddltionel IderdIII (s))
I 1000 - 079.00 - 07.00 - Rio 044.000 I I _ I
I J I I
CERTIFICATION
1 wrelty that all of 1M Items at Information entered an this corm■re uric and eemaet(b the head,at my knoebdge ane hrlist)and 1 rerdw•t■re that the enables of my eased#.I-abbrent TO matted fret Irenln will aaklect me b the pr•ebtenn of the insist low relative to the making Sad Nene of folse Instruments.
SELLER SIGNATURE I- BUYER CONTACT INFORMATION
r/ /211/201�^�' (Eider i:danmto raen buyThai r.is Nide:11.1. LLC, orfiduass.Than a.amix ado mink tock
Inco
la�'7_rG-LarLr. of an i ny.esww o onxly that k not o individualanswer
raoru u requiring
than R name cud must
be a ea". m
I cur cur iMNrdu•woAponehlo pity rdw Inn ene■ar qusaaww ngsmrhg era Irarnbr moat b errand.
9ELLEROCIVAITLIEV DATE Type or print clearly.)
fJ BUYER SIGNATURE
p� J Y usT WWe I FNar NAMF
rrvrnaoNATURE
BUYER'S ATTORNEY )
MEA CODE TCLCP1xN.E rAmaFN
Cirino. ESD. ! FNAMEAnn
�SAW JWMI I
STREET NJWER STRUT NAAL
631 1 271-8722
MEACODE MCP"MCNWwER ( I
NEW YORK STATE CrTVOR TOWN STATE ZIP CODE
COPY