Town of Brookhaven REVISED 3/28/19
Long Island
Please submit photocopies of the following items with your application. (No originals please, as they will not be returned to you)
NEW HOUSE, ADDITIONS & ANY CONVERSIONS TO LIVING SPACE:
-COPY OF BUILDING PERMIT
-COPY OF FINAL SURVEY
-COPY OF FINAL PLANS
-PHOTOS OF ALL SIDES OF THE HOUSE
IMPROVEMENTS & MODIFICATIONS:
-COPY OF BUILDING PERMIT
-COPY OF FINAL SURVEY
ONE CERTIFICATE OF ASSESSMENT PER PERMIT. AT LEAST 10 BUSINESS DAYS TO CERTIFY.
THE FOLLOWING MUST BE COMPLETED IN FULL
INCOMPLETE APPLICATIONS WILL NOT BE PROCESSED
PLEASE PRINT
APPLICANT NAME:____________________________________________________
PHONE #:_______________EMAIL________________________________________
PROPERTY ADDRESS:__________________________________________________
BUILDING PERMIT #:___________________________________________________
TYPE OF IMPROVEMENT:______________________________________________
S.C TAX MAP#:____________________________________ITEM#:______________
DISTRICT SECTION BLOCK LOT
CURRENT MARKET VALUE:____________________________________________
TOTAL SQ FT OF ADDITION:____________________________________________
MAP NAME:_____________________ LOT# ____ MODEL NAME:_____________
(NEW CONSTRUCTION, CONDOS & HOAS ONLY)
#ROOMS:_______ #BEDROOMS:_______ #FULL BATHS:_______ #HALF BATHS:_____
(INCLUDING BEDROOMS)
#STORIES:___________ #KITCHENS:____________ #FIREPLACES: ___________
STYLE:_____________________ EXTERNAL WALL TYPE:____________________
HEATING TYPE:____________ HEATING FUEL:________ CENTRAL AIR:_____
BASEMENT TYPE: FULL: ______ PARTIAL: ______ SLAB: ______ CRAWL: ______
RESIDENTIAL CERTIFICATE OF ASSESSMENT APPLICATION
PLEASE CONTACT THE DEPARTMENT OF ASSESSORS WITH ANY QUESTIONS: (631) 451-6300
APPROPRIATE FEE MUST BE SUBMITTED WITH ALL APPLICATIONS: NO CASH PAYMENTS ACCEPTED
PAYABLE TO THE TOWN OF BROOKHAVEN BY CHECK MONEY ORDER
or CREDIT CARD
(CREDIT CARD TRANSACTIONS INCUR A 2.35% CONVENIENCE FEE OR A MINIMUM FEE OF $1.50)
DATE:___________________ FEE: ___________________ CHECK#: _________________ CONTROL#: _________________
BUILDING PERMIT:
FINAL SURVEY:
FINAL PLANS:
PICTURES:
FORM COMPLETED:
PERMIT DESCRIPTION:__________________________________
____________________ RECEIVING CLERK:__________
Department of the Assessor
Richard P. DeBragga, Assessor
One Independence Hill, Farmingville, NY 11738 · Phone (631) 451-6300 · Fax (631) 451-6379
