Fill - Free fillable Application for a Mooring Permit (Town of Brookhaven) PDF form

Town of Brookhaven

PORT JEFFERSON HARBOR COMPLEX

Application for a Mooring Permit

Pursuant to the Town of Brookhaven Town Code Chapter 74

___________________________________________ _______ ________________________________________________________

Mooring Applicant’s Name

Applicant’s Address City, State and Zip Code

(______)_______________________ (_____)___________________________

Applicant’s Home Telephone Number Applicants Work or Cell Telephone Number

_____________________________________

Applicants Email Address

____________________________________________________________________(______)________________________________

Mooring Installer’s Name Installer’s Telephone Number

Residency:

___ Town of Brookhaven resident

___ Non-resident _____________________________

Town & State of residency

Mooring Location: (see attached chart) ____________________________________ (Depending on area Grid location may be assigned)

Mooring Area

CERTIFICATION:

The mooring owner and installer (if applicable) certifies that the above statements and information supplied with this application are true

and agrees that the issuance of the permit is based upon the accuracy thereof. As a condition to the issuance, the applicant agrees to

execute an Affidavit of Indemnity that must be submitted with this application.

Dated: _______

__________ __________________________________________

Signature of Mooring Applicant

Dated: _________________ __________________________________________

Signature of Mooring Installer (if applicable)

Schedule of mooring fees on last page of application along with return address

A complete mooring application under the Town Code of the Town of Brookhaven must

include:

1. A statement of authority (completed owner’s consent form) from the applicant for any agent making

application, if applicable.

2. The exact location of the mooring placed on the most current navigational chart with either longitude

and latitude indicated or distances to two permanent landmarks. Grid location may be applied.

3. An accurate description of the mooring system to be employed indicating the type and weight of the

anchor, the length of the chain, and the size and type of the mooring buoy (form included).

4. A notarized affidavit signed by the applicant and the agent/installer of the applicant.

5. Proof of residency and a copy of current boat registration for the mooring owner. In lieu of

registration, documentation papers of the vessel are acceptable. Moorings used for yacht clubs or

homeowners associations need not provide registration materials, however, it is expected that the

mooring be capable of holding in storm conditions, the largest vessel in the club or association.

6. Any fee as established by the Town Code.

FOR OFFICE USE ONLY:

Permit #- __________

Fee- ______________

Location- __________

Grid #- ____________

DATE IN:

Type of Mooring:

__________________________________________________________________________________________________________

Installers

Address City, State and Zip

Vessel: Sail

___ Sail/Aux. ___ Motor ____ Length over All ________ Beam _____________ Draft _______________

Make: ____________________ Vessel Name: _______________ Vessel Registration or Documentation #: ______________________

___ resident ___ non resident ___ underwater land Owner ___ Barge ___________ Yacht

Club Affiliation

click to sign

signature

click to edit

click to sign

signature

click to edit

Explanation of Rejection or Denial

Applications, which are rejected, may be resubmitted with all missing information.

Applications, which are denied, may be appealed to the Town Board of the Town of Brookhaven within 30 days of the denial. Requests

for appeals must be sent to the Town Clerk with a copy of the denial and any substantiation or documentation that you wish considered.

OWNERS CONSENT

Please be advised that I am the owner of the above mooring. I have read the application requirements for a

mooring permit, signed the application and I have read carefully, completed and signed in front of a notary

The Affidavit of Indemnity. I hereby consent to _________________________________________________ of

(Name of Agent)

________________________________________________ to make application and provide the necessary

(Firm name/corporate name)

information to the Town of Brookhaven for a mooring permit as required under the Town Code of the Town of

Brookhaven.

Please also be advised, that my agent should receive copies of all correspondence and a copy of the permit.

Sincerely,

_________________________________

Mooring applicant

_________________________________

Dated

AFFIDAVIT-OF-INDEMNITY

MOORING OWNER

Please read carefully.

I, _____________________________________, hereinafter referred to as mooring owner, residing at

________________________________________________________________________________________

County of __________________________, State of _____________________________, for the purposes of

obtaining a mooring permit pursuant to the Town Code of the Town of Brookhaven, herein having been duly

sworn does hereby depose and state that:

In consideration of the issuance of said permit, I do hereby agree to indemnify and hold harmless the Town

of Brookhaven, its employees, agents, servants and public officers of the Town of Brookhaven, against any and all

actions, claims and damages whatsoever for any loss to property or bodily or personal injuries or to death of any

person or persons, arising out of or due to intentional, willful or negligent acts or omissions of the above named

mooring owner. Additionally, I acknowledge, that by the issuance of this permit, the Town of Brookhaven, its

employees, agents, servants and public officers assumes no responsibility and makes no representations as to the

adequacy or sufficiency of the mooring system, equipment, tackle or anchors and that I am responsible for

determining the adequacy of the mooring system.

IN WITNESS WHEREOF I have hereto set my hand this __________ day of __________________,

__________________________________

State of ________________}

mooring applicant

County of _______________}

On the ___________ day of _________________________, _______ before me personally came

__________________________________________ to me known to be the individual described in and who

executed the foregoing instrument, and (s)he thereupon duly acknowledged to me that (s)he executed same.

Notary Public

________________________________

AFFIDAVIT-OF-INDEMNITY

MOORING INSTALLER

Please read carefully

I _____________________________________, ____________________________________________

Please identify your official title (corporate officer or member of partnership),

__________________________________________ or firm known as ________________________________,

(Corporate name)

Located at _________________________________________, County of __________________________, State

of _____________________________, herein referred to as the mooring installer and/or agent, for the purposes of

obtaining a permit pursuant to the Town Code of the Town of Brookhaven, in connection with the application filed

on behalf of ___________________________________, (the owner identified in said application), having been

duly sworn I hereby depose and say that:

In consideration of the issuance of said permit, the mooring agent/installer does hereby agree to indemnify

and hold harmless the Town of Brookhaven, its employees, agents, servants and public officers of the Town of

Brookhaven, against any and all actions. Claims, and damages whatsoever for any loss to property or bodily or

personal injuries or to death of any person or persons, arising out of or due to the intentional, willful or negligent

acts, or omissions of the above named mooring installer/agent. Additionally, the mooring agent/installer

acknowledges, that by the issuance of this permit, the Town of Brookhaven, its employees, agents, servants and

public officers, assumes no responsibility and makes no representations as to the adequacy or sufficiency of the

mooring system, equipment, tackle or anchors and the mooring owner/installer/agent is responsible for determining

the adequacy of the mooring system.

IN WITNESS WHEREOF I have hereunto set my hand this __________ day of __________________,

_______.

__________________________________

mooring Installer

CORPORATION

State of _______________________)

)ss.:

County of _____________________)

On the ___________ day of _________________________, ___________ before me personally came

__________________________________________ to me known, who being by me duly sworn did depose and say that (s)he resides at

________________________________________________, ____________________; that (s)he is the ______________________ of

_____________________________________, the corporation described in and which executed the foregoing instrument; that (s)he

knows the seal of said corporation and that the seal affixed to said instrument is such corporate seal; that it was so affixed by order of the

Board of Directors of said corporation and that (s)he signed his name thereto by like order.

________________________________

Notary Public

AFFIDAVIT-OF-INDEMNITY

MOORING OWNER

For yacht clubs, marinas, associations and other corporations.

Please read carefully.

I _____________________________________, ____________________________________________

Please identify your official title (corporate officer or member of partnership),

__________________________________________ or firm known as ________________________________,

(Corporate name)

Located at _________________________________________, County of __________________________, State

of _____________________________, herein referred to as mooring owner, for the purposes of obtaining a

mooring permit pursuant to the Town Code of the Town of Brookhaven, herein having been duly sworn does

hereby depose and state that:

In consideration of the issuance of said permit, I do hereby agree to indemnify and hold harmless the Town

of Brookhaven, its employees, agents, servants and public officers of the Town of Brookhaven, against any and all

actions, claims and damages whatsoever for any loss to property or bodily or personal injuries or to death of any

person or persons, arising out of or due to intentional, willful or negligent acts or omissions of the above named

mooring owner. Additionally, I acknowledge, that by the issuance of this permit, the Town of Brookhaven, its

employees, agents, servants and public officers assumes no responsibility and makes no representations as to the

adequacy or sufficiency of the mooring system, equipment, tackle or anchors and that I am responsible for

determining the adequacy of the mooring system.

IN WITNESS WHEREOF I have hereto set my hand this __________ day of __________________,

_______.

__________________________________

Mooring applicant

CORPORATION

State of _______________________)

)ss.:

County of _____________________)

On the ___________ day of _________________________, ___________ before me personally came

__________________________________________ to me known, who being by me duly sworn did depose and say that (s)he resides at

________________________________________________, ____________________; that (s)he is the ______________________ of

_____________________________________, the corporation described in and which executed the foregoing instrument; that (s)he

knows the seal of said corporation and that the seal affixed to said instrument is such corporate seal; that it was so affixed by order of the

Board of Directors of said corporation and that (s)he signed his name thereto by like order.

________________________________

Notary Public

Fill Online, Printable, Fillable, Blank Application for a Mooring Permit (Town of Brookhaven) Form

Related forms

Fillable Application for a Mooring Permit (Town of Brookhaven)

Fill Online, Printable, Fillable, Blank Application for a Mooring Permit (Town of Brookhaven) Form

Related forms

First 20 documents completely FREE!