AFFIDAVIT-OF-INDEMNITY
INDIVIDUAL
KNOW ALL MEN BY THESE PRESENTS:
That ____________________________________________, as owner 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, including his predecessors in-interest in any way resulting
from or arising out of any actions or 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______
_________________________________________
Owner’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)
