Fillable Accessory Apartment Application Packet PDF (Town of Brookhaven)

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Accessory Apartment Application Packet PDF (Town of Brookhaven)

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Building Division One Independence Hill, Farmingville, NY 11738 · Phone 631-451-6333 · Fax 631-451-6341 Rev. 10/2013
Town of Brookhaven
Long Island
GENERAL INFORMATION & INSTRUCTIONS
FOR A SPECIAL PERMIT FOR AN ACCESSORY APARTMENT
An application for a special permit for an accessory apartment is to be obtained from the Building Division. The completed
application paperwork and the application fee are to be submitted IN PERSON to the Accessory Apartment Review Board in the
Building Division:
A. APPLICATION signed and notarized.
B. FIVE SETS of FLOOR PLANS of the ENTIRE HOUSE. Plans are to show rooms and their sizes, as well as
ceiling heights (1
st
sty, 2
nd
sty, basement/cellar), size of all doors; windows must show clear opening size for
emergency egress (see diagram on how measurements should be taken). All rooms are to be labeled. PLANS
TO BE REVIEWED BY PLANS EXAMINER PRIOR TO APPLICATION.
C. TWO COPIES of your property SURVEY to SCALE
D. Copy of all pages of your RECORDED DEED.
E. PAAL OWNER AFFIDAVIT
F. FEE of $150. If paying by check, it is payable to the Town of Brookhaven.
G. Copies of all CERTIFICATE(S) OF OCCUPANCY issued for the subject premises.
H. DISCLOSURE AFFIDAVIT
I. PICTURES of house from front, rear, and sides as well as rear yard & front yard including driveway.
J. CERTIFICATION OF STRUCTURES FORM
K. Copy of Notice of Proposed Application sent to all adjacent and contiguous property owners by certified mail-
return receipt requested. Property owners and their addresses must be obtained from the Assessor’s Office, One
Independence Hill, Farmingville, New York 11738. FORMS NOT AVAILABLE ON LINE
L. Affidavit of Mailing listing all adjacent and contiguous property owners as provided by the Assessor’s Office.
FORMS NOT AVAILABLE ON LINE
M. Green receipts, white receipts and undelivered envelopes (if any) from the certificate mailing of the notices.
N. If and when your accessory apartment application is approved, a BUILDING PERMIT MUST BE OBTAINED
by the applicant for the work to be done and/or the change of use to an accessory apartment.
The following are some of the requirements that must be met (time shall be allotted) in order to grant temporary
Certificate of Occupancy for an accessory apartment:
• The house must be owner-occupied.
• The premises of the applicant must have one on-site paved (asphalt or concrete) parking space
per dwelling unit. Each parking space must have independent access to the roadway.
• The accessory apartment minimum size is 300 square feet and the maximum size is 40% of the
total house habitable area, not to exceed 650 square feet. (See 85-201.B(3) for larger
accessory apartment sizes under extenuating circumstances.)
• There shall be no more than one bedroom per accessory apartment. There shall be no more
than one accessory apartment per lot.
• The dwelling and premises must comply with all applicable requirements of the New York
State Uniform Fire Prevention and Building Code and the Brookhaven Town Code.
• Cellar apartments are permitted under certain circumstances, or with a variance from the N.Y.
State Board of Review.
Upon receipt of the completed application, the Building Division will inspect the dwelling and premises, review the application
and make recommendations to the Accessory Apartment Review Board. The Accessory Apartment Review Board will inform the
applicant of such item(s) (if any) that must be complied with to bring the dwelling and/or premises up to State and Town codes.
All such requirements must be met within 90 days from the date the building permit is issued.
A public hearing shall be held for each accessory apartment application before the Accessory Apartment Review Board. The date
for the public hearing shall be set and the public shall be notified of such hearing in an official newspaper at least 5 days prior to
the hearing. Applicants must notify all adjacent and contiguous property owners at least 12 days prior to such public hearing by
certified mail-return receipt requested. All such notices will be provided to the applicant by the Building Division. All applicants
must be present at their public hearing.
For further information, call (45l-6342) Monday through Friday, 9a.m.-4:30 p.m. or visit the Building Division Monday through
Friday 9a.m.-4:30p.m
___
Town of Brookhaven
Long Island
Building Permit Application
APPLICATION is hereby made for a permit to do the following work, which will be done in accordance with the description, survey and plans submitted pursuant to
Section 57 of the Worker’s Compensation Law, Zoning Ordinances, Building Code and all other applicable ordinances and laws. Article 15 of the Executive Law of the
State of New York, Section 296-5 (A) (1) prohibits discrimination in the sale, rental or lease of housing accommodations because of race, creed, color or national origin.
Select All That Apply
□
Residential Building Permit
□
Commercial Building Permit
□
Record Search
Certificate of Existing Use
□
Plumbing Work Form
(attached)
□
Accessory Apartment License
□
House Rental License
(supplement appl. needed)
□
Letter of
Correction
□
Renewal of permit/license#
Property Suffolk County Tax Map Number - District 0200 Section Block Lot(s)
Property Owner Name Phone eMail
Property Owner Current Address: Zip
Authorized Agent/Attorney Name Phone eMail
Authorized Agent/Attorney Address
Property located at No. N.S.E.W. side Distance
N.S.E.W. of Town NY
Description/ Request/Use/Size of proposed work
Project Name (if applicable):
Owner Certification
I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the above information and certify its
accuracy.
Owner Print Name Signature Date
OR
Agent Authorization
I hereby authorize to act as my agent(s) to apply for, sign, and file the documents
necessary to obtain a Building Permit / License for the project, as described above. Note: A copy of the owner’s driver’s license, form notarization, or
other verification acceptable to the agency is required to be presented when the permit is issued to verify the property owner’s signature.
County
of
}
:
ss
State of New York Owner Print Name Signature
On the day of in the year before me, the undersigned, 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 Public State of New York
Print Name Signature
Commission Number Expiration Date
Building Division • Phone 631-451-6333 • Fax 631-451-6341
Each application must be typewritten or printed and have all information answered. Incomplete or illegible applications will not be accepted.
B_APPLICATION Rev. 05/13
Town of Brookhaven
Long Island
PAAL Owner Affidavit
Building Division
One Independence Hill, Farmingville, NY 11738 · Phone 631-451-6333 · Fax 631-451-6341
AA_Affidavit Rev.. 05/2013
I, __________________________________________________being duly sworn, depose and say that I reside at
_____________________________________________ and that I am the owner in fee of the premises known
as_____________________________________________, SCTM Number _________________________and
that I have read the foregoing Accessory Apartment Application and know the contents thereof, that I make the
foregoing petition for the Provisional Accessory Apartment License. I will comply with all New York State
Uniform Fire Prevention and Building Code requirements, as well as, all Town of Brookhaven Code requirements
pertaining to the Provisional Accessory Apartment License and will meet these standards within ninety (90) days
of the granting of the license or the license will become null and void.
In consideration for the granting of permission for an Accessory Apartment, I consent to periodic inspections of
the subject premises during reasonable hours so that it may be determined that the premises remain in substantial
compliance with the representations set forth in the application herein, and that any tenancies that I may grant
shall be subject to such inspection(s).
I further agree that any extension of said Provisional Accessory Apartment License shall terminate upon my
death, upon the transfer of the title, or if the premises is no longer my principal residence.
I further swear/affirm that I am not a registered sex offender and that should I ever register as a sex offender
during the course of having a Provisional Accessory Apartment License, I shall notify the Town of Brookhaven
Building Department within 10 days of said registration and I acknowledge that my permit and/or Provisional
Accessory Apartment License will be deemed null and void immediately upon my registration as a sex offender.
I further swear/affirm that I am making such representations with full knowledge that the Town of Brookhaven is
relying on these statements as a basis for the issuance of a Provisional Accessory Apartment License.
I further acknowledge that the Town of Brookhaven may submit a copy of this affidavit in any proceeding
seeking to enforce any code, ordinance or regulation where it is alleged that I have breached a material
representation made herein.
I further acknowledge that I shall be liable for all direct and indirect costs incurred by the Town of Brookhaven to
obtain compliance and that costs shall be charged against the above referenced real property.
I have read this affidavit, had the opportunity to review it, and have retained a copy. I understand that the original
affidavit will be made part of the permanent record of the Accessory Apartment Application for the dwelling.
Signature of Owner: ________________________________________________ Date of Birth: ______________
Sworn to before me this ______day of
_______________________, 20_____
_______________________________
Notary Public, County of Suffolk
TOWN OF BROOKHAVEN
TRANSACTIONAL DISCLOSURE FORM
(Conflict of Interest Form)
A Transactional Disclosure form is required when someone submits certain applications to
Brookhaven Town. The purpose of the disclosure is to alert the Town if a party of influence
has an interest in this application or if someone within the Town who will participate in the
decision has an interest.
*Note: It is required that a copy of this form be sent to the Director of the Board of Ethics.
Name______________________________Address___________________________
City ______________________________________ State ____ Zip _________
Telephone ____________________ Email _______________ Fax ________________
This form is for:
 An individual  A partnership
 A corporation  An association
Nature of Application:
 Property Assessment Grievance for non-residential parcel  Variance
 Amendment  Change of Zone
 Approval of Plat  Exemption from Plat or Official Map
 License or Permit affecting real property  Bidding on contract(s)
Affected parcel (address) ______________________________________________________
Does any officer or employee of the Town of Brookhaven, member of an executive
committee of a political party, or his/her spouse, brother, sister, parent, child, grandchild or
spouse of any of them, have an interest in this application by virtue of being the actual
applicant, being the owner of the actual property or having an interest in the corporation,
partnership or association making such application? Yes ____ No ____
If Yes, complete the appropriate section below.
If No, sign and date at end of form.
Please complete the following relevant section below:
For individual:
Interested Party:
Name______________________________Address ___________________________
City ______________________________________ State ____ Zip _________
Page 1 of 2 Effective 5/15/2018
For corporation:
Interested Party:
Name______________________________Address ___________________________
City ______________________________________ State ____ Zip _________
Title _________________________ Department ____________________________
Relationship to Public Officer/Employee and Title, if other than Self: ________________
Yes ___ No ___ Is the owner of greater than five percent (5%) of the corporate
stock of the application when the applicant is a corporation whose
stock is publicly traded.
Yes ___ No ___ The actual applicant,
Yes ___ No ___ An Officer, Director, Partner, or Employee of the applicant, or
Yes ___ No ___ Legally or beneficially owns or controls any stock of a non-
publicly traded corporate applicant or is a member of a partnership
or association of the applicant.
For partnership or association:
Interested Party:
Name______________________________Address ___________________________
City ______________________________________ State ____ Zip _________
Title _________________________ Department ____________________________
Relationship to Public Officer/Employee and Title, if other than Self: ________________
Yes ___ No ___ Does the owner hold greater than five percent (5%) interest of publicly
traded shares?
Yes ___ No ___ The actual applicant,
Yes ___ No ___ An Officer, Director, Partner, or Employee of the applicant, or
Yes ___ No ___ Legally or beneficially owns or controls any stock of a non-
publicly traded corporate applicant or is a member of a partnership
or association of the applicant.
ALL APPLICANTS PLEASE FILL OUT BELOW:
Print Name _____________________________________ Date ________________
Signature ___________________________________________
Page 2 of 2 Effective 5/15/2018
Town of Brookhaven
Long
Island
Certification of Structures 3-2019
Must be completed by the owner for: *
Suffolk County Tax Map Number: 0200 _______/ /
Item Number: _____________
*Suffolk County Tax Map Number and Item Number can be found
on your Tax Bill
Please check below all structures or improvements currently located on the property. In order to receive a Certificate
of
Occupancy or equivalent for the proposed work all structures and/or improvements must be certified by the
Town of
Brookhaven.
Office Use Only
Primary Structure (e.g. main house)
Detached Garage
Garage Conversion
Barn
Apartment
Swimming Pool/Hot Tub
Greenhouse
Finished Basement
Outside Basement Entrance
Fireplace(s)
Porches/Screened Porches
Wood Platforms/Ramps
Fence(s)
Gazebo(s) How many?
Shed(s) How many?
Deck
Addition
Modification
Other
Covenants or Restrictions such as
Clearing Limits or Natural Buffers
Sports Court
Outdoor BBQ area/Outdoor Kitchen
I do hereby certify that all statements made by me in this certification of structures are true and correct to the best of my
knowledge, information and belief, further, I understand that in the event that I have knowingly and willfully made any
false statements, I will be liable for punishment in accordance with all applicable laws and statutes.
Owner Name: (Print) Date:
Signature:
Physical Property Address:
Mailing Address, if different:
Phone Number:
Email Address:
Building Division www.brookhavenny.gov
One Independence Hill, Farmingville, NY 11738 · Phone 631-451-6333 · Fax 631-451-6341
Town of Brookhaven
Long Island
Building Division 2-2014
Tullio Bertoli, AICP, Commissioner
Tara McLaughlin, Deputy Commissioner
Angus Graham, Chief Building Inspector
One Independence Hill • Farmingville, NY 11738 • Phone (631) 451-6333 • Fax (631) 451-6341
(Item#________________)
(SCTM#_______________________________)
AFFIDAVIT OF MAILING
PROPERTY OWNERS IMMEDIATELY ADJACENT & CONTIGUOUS TO THAT OF THE APPLICANT
INCLUDING OWNER(S)( OF PROPERTY SEPARATED FROM THAT OF THE APPLICANT(S) BY A
PUBLIC ROAD OR RIGHT-OF-WAY:
FIRST AND LAST NAMES
ADDRESSES
1.
2.
3.
4.
5.
6.
7.
8.
I HEREBY CERTIFY that the above named persons are all property owners immediately adjacent and contiguous to
that of the applicant(s) including owner(s) of property separated from that of the applicant(s) by a public road or
right-of-way and that all those property owners were notified by certified mail-return receipt requested.
____
______________________________________________
(Owner’s Signature)
__________________________________________________
(Owner’s Address)
__________________________________________________
S
worn to before me this _____ day of
_________________, ____________ .
____
___________________________
Notary Public, County of
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Accessory Apartment Application Packet PDF (Town of Brookhaven)

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Completed 15 July 2020

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