Town of Brookhaven
Application for Permit
DIVISION OF FIRE PREVENTION
One Independence Hill, Farmingville, NY 11738
(631) 451-6262 fax: (631) 451-6283
FP-10 rev 5/15
PLEASE TYPE OR PRINT CLEARLY
1. DATE OF APPLICATION:
2. FEE $: 3. TOB FILE NUMBER: (Previous assigned Permit Number)
4. Application is hereby made to the Chief Fire Marshal by the undersigned for permission for the following purpose:
5. NAME OF APPLICANT:
6. ADDRESS OF APPLICANT: PDLOLQJDGGUHVV
7. NAME OF BUSINESS & PREMISE:
8. STREET ADDRESS OF PREMISE: (IF DIFFERENT FROM APPLICANT)
9. SITE PLAN # IF NEW CONSTRUCTION OR ADDITION: 9a. TOTAL SQUARE FEET: (NEW CONSTRUCTION OR ALTERATION)
10. PARCEL NUMBER:
District:
0200
Section:
Block:
Lot:
11. BUILDING OWNER NAME:
12. ADDRESS:
If applicable, please enter the appropriate number in fields 13 thru 16
13. # OF POUNDS/GALLONS: 14. # OF FIRE HYDRANTS 15. # OF SPRINKLER DEVICES: 16. # OF FIRE ALARM DEVICES:
The accuracy of the information, plans, diagrams and other facts submitted in conjunction with this application
are the responsibility of the applicant. Any false statement made herein is punishable as a misdemeanor,
pursuant to Section 210.45 of NYS Penal Law.
17. PRINT NAME OF APPLICANT:
18. PHONE: 19. FIRE DISTRICT:
20. SIGNATURE:
* * * * * * * * * * * * * * * * * * * * DO NOT WRITE BELOW THIS LINE! * * * * * * * * * * * * * * * * * * * *
FIRE MARSHAL APPROVAL
Based upon the information, plans, diagrams and other facts submitted in conjunction with this application and/or
conditions readily observed at the time(s) of inspection to indicate that the premise is substantially in compliance with the
intent of the Fire Prevention Local Law of the Town of Brookhaven, this Application is hereby:
New Permit Number:
APPROVED
□ or DENIED □
(check one)
Total Occupancy Load:
FIRE MARSHAL: FIRE MARSHAL NUMBER: DATE ISSUED: DATE EXPIRES:
Additional Requirements Are Listed On The Permit
The Permit associated with this application is issued and accepted on condition that the provisions of the Code
of the Town of Brookhaven and any additional requirements of the Permit are complied with. Any violation of
said Code may result in the immediate revocation of the Permit. No responsibility rests upon the Town, the Fire
Marshal or the Fire District by reason of this Permit.
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