Fillable Form PL-01 rev E 1/1/2019: Brookhaven Land Use (Town of Brookhaven)

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Form PL-01 rev E 1/1/2019: Brookhaven Land Use (Town of Brookhaven)

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Town of
Brookhaven
Long Island, New York
Land Use Application
One Independence Hill, Farmingville, NY 11738
Form PL-01 rev E 1/1/2019
Page 1 of 11
Application is hereby made to
the Town of Brookhaven for
the application type
requested.
By application submittal, the
applicant does hereby
authorize employees or
agents of the Town of
Brookhaven to enter and
inspect the project site as
necessary in conjunction with
this application.
Please check the appropriate application request:
1. TOWN BOARD:
1a. AMENDMENT OF RESTRICTIVE COVENANT (TBR)
1b. CHANGE OF ZONE (CZ)
1d. SPECIAL PERMIT (CZ)
2. PLANNING BOARD:
2a. AMEND RESTRICTIVE COVENANT (Relief of Covenant) PBR
3a. CHANGE OF USE - CU
(including facade and minor additions up to 500 sf)
2b. FINAL SUBDIVISION - FS
3b. FIRE/AMBULANCE, ETC. - OM
2c. LAND DIVISION - LD
2e. PRELIMINARY FINAL SUBDIVISION - FS
2f. PRELIMINARY SUBDIVISION - PS
2g. ROAD IMPROVEMENT/RESUBDIVISION - RI
2h. SINGLE FAMILY RESIDENCE - SF
2i. SITE PLAN- SP
2j. SPECIAL PERMIT - SP
3c. TEST HOLE - TH
3d. TREE CLEARING - TC
2k. 278 CLUSTER TREATMENT (Submitted w/PS, FS, PF, LD or RI)
1c. PLANNED DEVELOPMENT DISTRICT (PDD)(CZ)
Case Number:
Application Date:
Town Use Only
2d. PLANNING BOARD VARIANCE
3e. REVEGETATION PLAN- RV
3. PLANNING DIVISION:
2l. OTHER:
Print Form
I. GENERAL APPLICATION:
A. PROPERTY LOCATION:
Name of Application:
Located at #:
N E S W
side of:
, on the
Property Size (Acres):
Distance:
, N
E
S
W
of:
Hamlet
Ambulance District:
Fire District:
School District:
Post Office:
Present Zoning/Use of Site Proposed Zoning/Use of Site
Scope of Proposed Work: (Please list all SCTM #'s associated with application)
Town of
Brookhaven
Long Island, New York
Land Use Application
Page 2 of 11
Form PL-01 rev E 1/1/2019
Name of Subdivision:
Subdivision Lot Number:
Yes No
Does the property in question conform to the lot area requirement?
Disturbed Property Size (Acres):
DISTRICT SECTION BLOCK LOT
- - -
Suffolk County Tax Map (SCTM) Property Number: (Use "Scope of Work" section
below to list any additional SCTM #'s)
Square Feet:
Square Feet:
OR
OR
*Total Proposed S.F. of Building(s):
0
0
0200
B. PROPERTY OWNER/ENTITY CONSENT: (separate sheets may be used for multiple owners)
Be advised that I am the owner of record of the property referenced herein and hereby consent to this application. By this
application, the owner does hereby authorize employees or agents of the Town of Brookhaven, in conjunction with this
application, to enter and inspect the project site as necessary.
Owner/Entity Name:
Address:
Hamlet: State: Zip:
IN WITNESS WHEREOF I have hereto set my hand onto this day of ,
Sign By Owner/Officer
Town of
Brookhaven
Long Island, New York
Land Use Application
Page 3 of 11
Form PL-01 rev E 6/2/15
STATE OF NEW YORK )
) ss.:
COUNTY OF SUFFOLK )
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 individuals(s), or the person upon behalf of which the individual(s) acted, executed the instrument.
Tel#:
Fax#:
If corporation, name of responsible officer: Title
Notary Public
E-mail:
Firm Name:
Town of
Brookhaven
Long Island, New York
Land Use Application
Page 4 of 11
Form PL-01 rev E 6/2/15
Firm Name:Name:
City: State: Zip:
Tel#:
Fax#:
C. APPLICANT/CONTRACT VENDEE/LESSEE
(If same as owner, state in name field below)
D. PLAN PREPARER
Zip:
Street Address:
Name:
City: State:
Tel#:
Fax#:
Firm Name:
E. ATTORNEY/AGENT (If applicable):
Zip:
Street Address:
Name:
City: State:
Tel#:
Fax#:
Firm Name:
E-mail:
E-mail:
E-Mail:
Street Address:
Engineers Certification:
The site plan or subdivision submitted to the Board depicts an excess of cubic yards, proposed to be
removed from the premises.
Signature:
F. Removal of Excess Materials
Name:
License Number:
Phone Number
E-mail:
Date:
Town of
Brookhaven
Long Island, New York
Land Use Application
Page 5 of 11
Form PL-01 rev E 6/2/15
On the _____ day of ___________________, in the year ________, before me, the undersigned, a Notary Public in and for said
State, 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 they by his/her/their signature(s), on the instrument, the
individual(s), or the person(s) upon behalf of which the individual(s) acted, executed the instrument.
II. BOARD OF ETHICS TRANSACTIONAL DISCLOSURE:
Does any officer of the State of New York, officer or employee of the Town of Brookhaven, officer or
employee of Suffolk County,officer of a political party in Suffolk County or his or her spouse, brother,
sister, parent, child, grandchild, or the spouse of any of them have an interest in this application by
virtue of being the actual applicant, or, by virtue of having an interest in the corporation, partnership,
or association making such application?
B. If you checked "Yes" above, please complete the following section below:
Interested Party and Nature of Interest:
Zip:
Address:Name:
City: State:
Title: Department:
Relationship to Public Officer/Employee and Title if other than Self:
1. 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 listed on the New York or American Stock Exchanges,
2. The actual applicant,
3. An Officer, Director, Partner, or Employee of the applicant, or ,
4. 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.
Yes No
Yes No
Yes No
Yes No
Yes No
Print Name:
Notary Public:
Signature:
A. APPLICANT
Address:Name:
City: State: Zip:
Tel#:
Fax#:
Application Date:
Case Number:
E-Mail
Town of
Brookhaven
Long Island, New York
Land Use Application
Page 6 of 11
Form PL-01 rev E 6/2/15
III. A. PROJECT DATA
1. Is the property within 500' of the boundary of any village or town?
2. Within 500' of any existing or proposed County or State Parkway, Thruway, Expressway or highway?
3. Within 500' of any existing or proposed boundary of any County, State or Federal owned land?
4. Within 500' of any existing or proposed place of public assembly?
5. Within 100' of any freshwater or tidal wetland system?
6. Within Carmans River Watershed area?
7. Within a designated Historic District or Historic District Transition Zone?
Village/Town
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
8. Are there any existing covenants or restrictions affecting the premises for which the approval is sought?
If Yes, please attach a copy certified by the Suffolk County Clerk.
9. Are there covenants or conditions being offered which would affect the use or development of this
property?
10. Is the property improved with any structures or signs? If Yes, attach a copy of any Certificate of
Occupancy(s), Certificates of Existing Use(s), and/or Certificate of Zoning Compliance(s) for all of the
existing structures and/or signs.
11. Is the property located within the New York State Hydrogeologic Sensitive Zone?
12. Is the property located within the New York State designated Central Pine Barrens area?
13. Is there any Pine Barrens Credits being purchased?
14. Does the owner/applicant own or have any interest in any contiguous property?
If Yes, list the SCTM numbers below:
15. Have you applied for Health Department approval for sanitary waste for the proposed use?
16. Do any Special Districts or utilities service the site?
If Yes, please explain below:
Yes NO
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
17. Will there be any use, manufacture, or disposal of any hazardous materials, and/or ground water
resources be utilized in any other way other than for normal potable consumption , and/or any air, noise
or light emissions occur. If Yes, please explain below:
Yes No
Yes No
Yes No
18. Is the property located on an improved road?
19. Is the road Town maintained?
20. Does the proposed property disturb more than one acre of land? If Yes, please prepare a Stormwater
Pollution Prevention Plan.
21. Is the property located within a designated Zoning Overlay District?
22. Was the property subject to a public hearing on a change of zone application within the last 12 months?
Yes No
Yes No
Yes No
NoYes
NoYes
Town of
Brookhaven
Long Island, New York
Land Use Application
Page 7 of 11
Form PL-01 rev E 6/2/15
III. B. PROJECT DATA: ECONOMIC IMPACTS
Completed for all commercial/industrial projects and residential projects greater than 10 Units
(If not applicable, check here and go to Section IV)
1. Does project involved Local, State or Federal funding?
2. If single phase project:
3. If multi-phased:
d. Is Phase 1 functionally dependent on subsequent phases?
N/A
NoYes
Anticipated period of construction months. (including demolition).
a. Total number of phases anticipated.
b. Expected date of commencement Phase 1. (including demolition)
c. Approximate completion date of final phase. (month/year)
NoYes
4. Number of jobs generated during construction. (full time equivalent)
6. Number of jobs eliminated by this project.
7. What are the current tax revenues generated by the project site?
8. What tax revenues will project generate after completion?
9. What is the estimated cost of construction?
10. How many schoolchildren is the project expected to generate?
N/A
11. What is the estimated cost of educating the school-age
children generated by the completion of this project?
N/A
5. Number of jobs generated after completion. (full time equivalent)
Town of
Brookhaven
Long Island, New York
Land Use Application
Page 8 of 11
Form PL-01 rev E 6/2/15
IV. SPECIAL USE PERMITS & VARIANCES:
A1. If the proposed project requires a Special Permit, please check the appropriate Board and describe the Special Permit
request in the space below:
B1. If he proposed project requires Variances, or Waivers, please check the appropriate Board, state the nature of the
request and the reason in the space below:
Town Board Planning Board Zoning Board of Appeals
Town Board Planning Board Zoning Board of Appeals
Lot Area
Lot Width
Front Yard Setback
Rear Yard Setback
Side Yard Setback
Minimum Total
1st Story Sq. Ft.
2nd Story Sq. Ft.
Special Permit
Criteria
2. VARIANCES/WAIVERS REQUESTED: Please check the type of variance/waiver request and specify the size proposed:
[Note: Upon application review, additional variance/waiver request(s) may be added by Town Application Examiners.]
3. List the structure(s) requiring variance/waiver(s): Specify whether each structure is PROPOSED or EXISTING:
Other
V. SUBDIVISION/LAND DIVISION:
A1. Complete for all subdivision/land division/road improvements
Date: Liber: Page:
Number of Lots:
Deed(s) recorded in the Suffolk County Clerk's Office:
2. Are there encumbrances or liens against this land other than mortgages?
3. Will the final plat be filed in sections, or will it cover the entire preliminary layout?
4. Are all the public open spaces shown on the layout to be dedicated for public purposes?
5. How many acres are to be dedicated for public park or playground purposes?
NoYes
Yes No
Yes No
Town of
Brookhaven
Long Island, New York
Land Use Application
Page 9 of 11
Form PL-01 rev E 6/2/15
C1. If he proposed project requires an Amendment to a Restrictive Covenant, please check the appropriate Board and
describe: A) Existing covenant for which relief is sought; B) Description of requested relief; and, C) Reason for requested
relief, in the space below:
Planning BoardTown Board Zoning Board of Appeals
2. Percentage of current covenant area affected:
Proposed percentage of covenant area affected:
3. Percentage of current buffer area affected:
Proposed percentage of buffer area affected:
%.
%.
%.
%.
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Form PL-01 rev E 112019: Brookhaven Land Use (Town of Brookhaven)

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Completed 12 February 2021

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