AFFIDAVIT-OF-INDEMNITY
INDIVIDUAL
(Contract Vendee)
KNOW ALL MEN BY THESE PRESENTS:
That ____________________________________________, as the contract vendee of the project
property and hereinafter referred to as Applicant, residing at _______________________________________,
________________, County of _______________________, State of _________________, for the purpose of
obtaining a Permit pursuant to Chapter 81, Section 81-9 and/or Chapter 76 of the Code of the Town of
Brookhaven, having been duly sworn does hereby depose and say that:
In consideration of the issuance of said permit, the Applicant does hereby agree to indemnify and save harmless
the Town of Brookhaven, its employees, agents and public officers, against any and all damages to property or
injuries to or death of any person or persons, including property and employees, public officers, or agents of the
Town of Brookhaven, and shall defend, indemnify, and save harmless the Town of Brookhaven, its employees,
agents, and public officers, from any and all claims, demands, suits, actions, or proceedings of any kind or
nature, of or by anyone whomsoever, in any way resulting from or arising out of operations connected with the
issuance of the permit. This indemnification shall be binding upon any assignees, heirs or successors in-
interest.
Additionally, the applicant does hereby agree to allow employees of the Town of Brookhaven, in conjunction
with this application, to inspect the project site as necessary.
IN WITNESS WHEREOF I have hereto set my hand this ____ day of ____________________, 20______
_________________________________________
Contract Vendee's Signature
STATE OF NEW YORK¬
¬ss.:
COUNTY OF SUFFOLK¬
On the ____ day of _________, in the year 2 , before me, the undersigned, a Notary Public in and for said State, personally
appeared ______________________________________, personally known to me or proved to me on the basis of satisfactory
evidence to be the individual(s) whose name(s) is(are) subscribed to the within instrument and acknowledged to me that he/she/they
executed the same in his/her/their capacity(ies), and that by his/her/their signature(s) on the instrument, the individual(s) or the person
upon behalf of which the individual(s) acted, executed the instrument.
_______________________________________
(Notary)
