Fillable 500 LIST REQUEST FOR TOWN BOARD (LAND USE (Town of Brookhaven)

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500 LIST REQUEST FOR TOWN BOARD (LAND USE (Town of Brookhaven)

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500’ LIST REQUEST
FOR TOWN BOARD (LAND USE APPLICATION)
*INCLUDES LABELS FOR 500’ CERTIFIED OR REGISTERED MAIL*
APPLICANT: ______________________________________________________________
ADDRESS: ______________________________________________________________
PHONE #: ______________________________________________________________
REASON FOR REQUEST: ___________________________________________________
PARCEL SCTM#: __________ - __________ - __________ - __________
DISTRICT SECTION BLOCK LOT
OR
PARCEL ITEM#: ______________________
PARCEL ADDRESS: ________________________________________________________
OWNER NAME: ____________________________________________________________
SIGNATURE: ____________________________ DATE: ___________________________
Town of Brookhaven
Long Island
Edward P. Romaine
, Su
pervisor
Department of the Assessor
Richard P. DeBragga, Assessor
One Independence Hill •
Farmingville •
NY 11738 •
Phone (631) 451-6300 •
Fax (631) 451-6379
www.brookhavenny.gov
printed on recycled paper
FOR OFFICE USE ONLY
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500 LIST REQUEST FOR TOWN BOARD (LAND USE (Town of Brookhaven)

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Completed 2 August 2020

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