Fillable Commercial Sign Permit Checklist (Town of Brookhaven)

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Commercial Sign Permit Checklist (Town of Brookhaven)

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File type: PDF

U.S.A. forms for Town of Brookhaven

BROWSE TOWN OF BROOKHAVEN (NY) FORMS

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Commercial Sign Permit Checklist
Workers Compensation and Disability Insurance for the contractor. e only Certicates of
Insurance forms accepted are: Workers Compensation - C-105.2, SI-12, U-26.3, GSI-12, WC/
DB-100,WC/DB-101 Disability - DB-120.1, DB-155. Town of Brookhaven must be named as
Certicate Holder. Accord Forms will not be accepted. For additional information call Walter
Peretti at NYS W/C Board: (518) 402-8330.
One (1) Copy of each Certicate of Occupancy/Compliance for all existing buildings and uses.
Please provide either a valid Building Permit or a Certicate of Compliance for the business you are requesting a
sign permit for.
One (1) Copy of a Property Survey to Scale - Must be legible.
If applying for a Detached Ground Sign, please note the location and proposed setbacks from the adjacent
property lines.
One (1) Copy of Recent Property Tax Statement - Must be legible. Approval.
Construction Cost Estimate, to be completed by Architect, Engineer, or General Contractor.
Required For: Detached Ground Signs Only Cost of Construction Of: Foundation, Masonry & Structural Steel.
Historic District Approval. Call: (631) 451-6455
Required For: New Buildings, Additions, and any Exterior Work if located in a designated Historic District.
Trac Safety Speed Limit. Call: (631) 451-6480
Required For: Detached Ground Signs Only Speed Limits on adjacent roadways obtained from Town of
Brookhaven Trac Safety.
Town of Brookhaven
Long Island
Building Permit Application
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
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
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):________________________________________________________________________________________________________________
□ 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# ________________________
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.
State of New York Owner Print Name_____________________________________Signature________________________________________
County of ______________
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 ______________________________
}:
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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:
 Tax 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 _________
Effective 11/1/10
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 ____________________________________________
Effective 11/1/10
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Commercial Sign Permit Checklist (Town of Brookhaven)

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Completed 2 August 2020

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