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FORM AVAILABLE ONLINE: Town of Brookhaven Long Island (Town of Brookhaven)

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Town of Brookhaven
Long Island
Building Division
Beth Reilly, Esq., Commissioner
Tara McLaughlin, Deputy Commissioner
Angus Graham, Chief Building Inspector rev. 1-2020
One Independence Hill, Farmingville, NY 11738 • Phone 631-451-6333 • Fax 631-451-6341
BUILDING PERMIT REQUIREMENTS
BUILDING PERMIT APPLICATION – completed and signed (make sure that you have the correct mailing address for the
applicant, engineer/architect and builder). FORM AVAILABLE ONLINE www.brookhavenny.gov
PLUMBING PERMIT APPLICATION – completed, signed by plumber (If homeowner is doing work, sign bottom of application).
FORM AVAILABLE ONLINE
TRANSACTIONAL DISCLOSURE – completed and sign
CERTIFICATION OF STRUCTURES FORM – completed and signed.
EXISTING CONSTRUCTION AFFIDAVIT—completed and notarized
AFFIDAVIT FOR HEALTH DEPARTMENT REQUIREMENTS—(additions to existing structures)
SURVEYS – ONE ORIGINAL AND THREE COPIES Surveys must be legible, full size and to scale. SURVEY MUST BE NO
OLDER THAN ONE YEAR FROM DATE OF APPLICATION. The surveyor’s seal and the survey date and/or revision date must
be on the survey. The distance from the nearest tie street must be indicated. Pencil in existing/proposed additions or accessory
structures, show exact dimensions and distance to property lines.
PLANS – THREE (3) SETS OF CONSTRUCTION PLANS AND A DIGITAL COPY IF AVAILABLE FOR ALL PERMITS.
Proposed and existing additions to one- and two- family residences 700 square feet or larger and all second story additions must have
plans prepared by a Registered Architect or Professional Engineer. Plans to be a minimum scale of ¼” to one foot. Plans must
demonstrate compliance with the NYS Uniform Fire Prevention and Building Code and the Energy Code of NYS including all
dimensions, structural details, insulation values, anchor bolts, hold downs and strapping details, windows and door styles and sizes,
live and dead loads, siding and roofing materials, ventilation details and uses for each space.
Manufacturer’s specifications are to be submitted for heating units, air-conditioning units, stoves and factory-built fireplaces.
New dwelling plans must be dropped off for review. See the Residential Drop-Off Plans Checklist for detailed submission
requirements.
CERTIFICATES - For all structures, 1 COPY of all Certificates of Occupancy, Compliance, Existing Use, or Zoning Compliance.
WORKERS COMPENSATION AND DISABILITY – (Proposed Structures) – The only Certificate of Insurance forms accepted
as proof of Workers Compensation from builder/contractor are: C-105.2 (9-07), SI-12, U-26.3, GSI-105.2, WC/DB-100, and
Disability are: WC/DB-100, DB-120.1 or DB-155. The Town of Brookhaven Building Department must be named as Certificate
Holder. NO ACORD FORMS WILL BE ACCEPTED. If the HOMEOWNER is doing their own work, they must complete form
BP-1 and HAVE IT NOTARIZED. For additional information please call Walter Peretti at NYS WC Board 518-402-8330.
SPECIAL FLOOD HAZARD AREAS—Properties located in the Special Flood Hazard Area must submit a “Floodplain
Development Permit Application” with the Building Permit Application.
Nitrogen Protection Zone—Properties located in the Nitrogen Protection Zone will require approval of the Town of Brookhaven
Environmental Division prior to the issuance of a building permit for certain scopes of construction.
FEE-You must pay when application is accepted based on sq. footage cost and/or cost of materials, or other basis as specified in the
Town Code. (Minimum $66.24) Cash/Check/Credit cards are accepted.
UNIVERSAL DESIGN PERMIT FEE- To qualify for the reduced fee your plans must demonstrate compliance with the Universal
Design criteria as specified in Town Code 16-5.
Suffolk County Health Dept. (If applicable) 852-5700
Environmental permits (T.O.B.) and/or (N.Y.S.) (if applicable)
Historic District Advisory Committee (T.O.B.) approval (if applicable)
Homeowners Association approval letter (If you reside in a condominium, townhouse, co-op or certain residential areas)
Be advised that effective February 1, 2018, an original property survey or updated
survey no greater than one-year old, showing all structures currently on the property, is
required to be submitted with all residential building permit applications except for the
following:
- Alteration of existing space. Survey may be more than one year. (Alteration
of space does not include the addition of space)
- Conversion of existing space to habitable space. e.g. garage conversion,
finishing a basement. Survey may be more than one year old.
- Applications for licenses. A survey for a Rental Registration or Accessory
Apartment may be more than one-year.
- Renewal of a Building Permit.
The purpose of the survey requirement at application is to provide sufficient
information to enable the Building Division to make an accurate determination
regarding what buildings, structures, and improvements exist with the benefit of a
Certificate and which may require a permit. We anticipate that a more accurate review
at the time of the permit application will result in a smoother process for the issuance of
the Certificate of Occupancy.
In the above policy it is not required to provide a current survey when renewing a
permit. However, when a current survey for completed work is available at the time of
renewal it allows Building Division staff to identify structures on the property that are
not in compliance with Town Code. This will allow the applicant to address
their problems prior to the C.O. process.
The above survey requirement does not change the requirement for a final survey.
___
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
□
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
New construction must have a plumber’s signature.
Owner’s signature is acceptable only for an existing residential
Dwelling where the owner is doing the plumbing work. 1-2019
Plumbing HVAC Worksheet
Building Permit #: ___________ Date of Permit: __________Residential________Commercial: _________Worksheet Date:_________
Location of Building: _________________________________________ Section: ___________ Block: ___________ Lot: ____________
Owner Name: _____________________________________ Address: _______________________________________________________
Basement
1
st
Floor
2
nd
Floor
3
rd
Floor
Other
Fee
Total Units
Air Handlers
Blowers/Boilers/Space Heaters/Furnace
Central A. C.
Bath Tubs
Showers
(Floor) Drains
(Roof) Drains
Hand Sink
Kitchen Sinks
Lavatories (Bathroom Sinks)
Stacks (Number Of) Residential
Stacks (Number Of) Commercial
Urinals
Water Closets (Toilets)
Dishwasher
Drinking Fountain
Hot Water Supply – Oil/Gas Tank-less
Hydronic Solar Collectors
Indirect Waste
In-ground Tank Installation
Lawn Sprinklers
Outlet (Future)
Outside Hose Bibs
Utility Sinks/Laundry Tubs
Washing Machines
Other ( )
Other ( )
Total Fees:
Town of Brookhaven
Building Division
One Independence Hill, Farmingville
NY 11738 • Phone 631-451-6333 • Fax 631-451-6341
Plumbing Business Name: __________________________________
Business Address: _________________________________________
Telephone Number __________________________
Suffolk County Consumer Affairs License ______________________
Expiration Date: _____________________
Plumbing work is being done by:
Owner Signature_________________________________
Agent Signature__________________________________
OR
________Licensed Plumber
Signature ________________________________________
Printed Name_____________________________________
________________________________________
Notary Signature
Effective
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
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FORM AVAILABLE ONLINE: Town of Brookhaven Long Island (Town of Brookhaven)

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Completed 2 August 2020

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