Fillable HDAC-Application-Packet-PDF HISTORIC DISTRICT APPLICATION CHECKLIST

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HDAC-Application-Packet-PDF HISTORIC DISTRICT APPLICATION CHECKLIST

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LAST REVISED 7/2020 1
HISTORIC DISTRICT ADVISORY COMMITTEE (HDAC)
APPLICATION PROCEDURES
An application for Historic District Advisory Committee (HDAC) review can be obtained from the
Planning Division or the Town’s website, www.brookhavenny.gov. The completed HDAC application, with
required attachments (see requirements for a complete application on the following page) must be
submitted to the Planning Division, digitally & 1 hard copy. Incomplete applications will not be reviewed.
It is strongly advised that the applicant submit for preliminary HDAC review very early in the design
process. Preliminary sketch plans, in addition to all required materials (see the following page for detailed
requirements) are acceptable for this level of initial design review.
The completed application will be reviewed by the HDAC. The HDAC will then submit recommendations
to the Commissioner of the Department of Planning, Environment and Land Management (PELM). After
receiving recommendations from the HDAC, the Commissioner of PELM will make a final determination
on the application in a letter which will be sent to the owner(s) and applicant(s).
HDAC meetings are generally scheduled on the second Tuesday of each month at Town Hall (unless the
meeting is to be held virtually), unless a holiday occurs. Contact the Planning Division at (631) 451-6400 or
visit the Town’s Website for detailed scheduling information. All applications must be received no later
than the Wednesday before the meeting in order to be scheduled.
Upon completion of construction and prior to issuance of a Certificate of Occupancy/Certificate of
Compliance, be advised that you must submit color photographs depicting all sides of the completed
structure(s) to the Planning Division for a determination of conformance with the approved plans &
conditions of the approval by the HDAC and the Commissioner of PELM. Note that conformance with
HDAC approved plans and any conditions of HDAC approval is required. Should any changes to the
approved plans be considered, or if you have any issues with the conditions of approval, you must submit
revised plans and/or a written request for re-consideration PRIOR TO CONSTRUCTION.
THE FOLLOWING FEE SCHEDULE APPLIES TO COMMERCIAL APPLICATIONS ONLY:
New Commercial Construction under 20,000 SF $ 1,099.85
New Commercial Construction over 20,000 SF $ 3,299.54
Commercial Additions, Alterations: $ 549.92
Additional Penalty Fee for construction without prior approval (commercial) $ 659.91
Revisions (commercial) $ 164.98
Certificate of Occupancy Signoff (commercial) $ 274.96
LAST REVISED 7/2020
2
REQUIREMENTS FOR A COMPLETE HDAC APPLICATION
1. HDAC application (completed and signed, note that online application is forms fillable & that email
addresses must be provided).
2. Affidavit of Indemnity (completed & signed, only use the form that applies to the nature of
ownership: individual, contract vendee, or corporation).
3. Transactional Disclosure Form (completed & signed).
4. Owner’s Consent Form (completed & signed, if applicable).
5. Appropriate fee - for commercial applications ONLY (see fee schedule on page 1).
6. If there are existing structures on the property: Copy of any and all CO’s (Certificates of
Occupancy), CZC’s (Certificates of Zoning Compliance), CC’s (Certificates of Compliance) and/or
CEU’s (Certificates of Existing Use).
7. Board of Zoning Appeals grant letter, if a variance is needed (If variance application is pending,
indicate same on application and submit grant letter upon receipt.).
8. Survey map/site plan showing existing and proposed conditions.
9. Plans, As Applicable to application type. Contact the Planning Division if you have questions
regarding plan requirements. For initial design review, preliminary sketch plans are encouraged. Be
advised that following initial design review, submission of complete architectural building plans will
be required. If applicable, all plans are to be stamped, signed and dated by a registered architect or
licensed professional engineer (if plans are not prepared by a registered architect or licensed
engineer, please provide proof of approval from the Building Plans Examiner).
10. Detailed specifications / cut sheets for all exterior building materials & materials list.
11. Recent color photographs of the property depicting all four (4) sides of any and all buildings and
structures on the property, including view from the street). *
12. Several recent color photographs of properties including structures (view from the street) adjacent to
and across the street from the subject property, clearly labeled as to address or Suffolk County Tax
Map Number (SCTM). If necessary, submit a key map. *
13. For Applications That Involve DEMOLITION, the Following Requirements Also Apply:
a) Preliminary development plans for the property.
b) Historical data/information on the structure to be removed and surrounding site.
c) Detailed cost analysis prepared by a licensed professional evaluating the cost of demolition and
new development to the cost of restoration of existing structure(s).
14. ALL MATERIALS LISTED ABOVE ARE TO BE SUBMITTED DIGITALLY (PDFS
DIRECTLY ATTACHED TO EMAIL: PLANNINGSTAFF@BROOKHAVENNY.GOV), IN
ADDITION TO ONE (1) HARD COPY WHICH MAY BE DROPPED OFF AT TOWN HALL OR
MAILED TO:
Town of Brookhaven
Planning Division / HDAC
One Independence Hill
Farmingville, NY 11738)
* For the hard copy, photos should be mounted or printed on letter or legal size paper, with description of
what is shown in each photo clearly labeled on the front of the paper. For digital submission, provide a pdf
or word document of the photos & description of what is shown in each photo.
HISTORIC DISTRICTADVISORY COMMITTEE (HDAC) APPLICATION
Application is hereby made to the Town of Brookhaven Department of Planning, Environment & Land Management for
release of a project located within a Historic District, Historic District Transition Zone or Historic Landmark:
For additional information contact: Town of Brookhaven, Planning Division, One Independence Hill, Farmingville, NY 11738
PROPERTY OWNER’S
NAME
APPLICANT’S NAME (IF DIFFERENT FROM OWNER)
Mailing Address/PO Box Mailing Address/PO Box
Hamlet State Zip Code Hamlet State Zip Code
Phone Number & Email Address Phone Number & Email Address
CORPORATE APPLICANT: Responsible Officer: ________________________________________ Title: ___________________________
AGENT’S NAME
Mailing Address/PO Box
Hamlet State Zip Code
Phone Number & Email Address
APPLICATION HAS BEEN MADE FOR:
Zoning District:
Building Permit
Moving Permit _________________
Demolition Permit
Subdivision Property Area:
Site Plan
Variances
Special Use _________________
Sign Permit SF / Acres (circle one)
Solar Panel Installation
Exterior alterations
(
siding, roofing, window replacement, etc.)
Other
- -
Property Address:
N S E W (circle one) side of
(Name of street)
PROPERTY LOCATION:
Hamlet/Historic District:
Tax Map #: 0200 -
House No.
Distance:
feet N S E W (circle one) of
(Name of nearest cross street)
Subdivision Name and Lot # (if applicable):
PROJECT DESCRIPTION: (attach additional sheets if necessary)
ARE ANY VARIANCES NECESSARY FROM THE BOARD OF ZONING APPEALS (BZA) TO ACCOMPLISH THE ABOVE
REQUEST(S)? Yes No
If yes, please provide BZA Hearing Date & Case Number:
CERTIFICATION:
The applicant/owner of the property certifies that the above statements are true and agrees that the issuance of any approval from the Commissioner
of Planning, Environment & Development is based on the accuracy thereof. As a condition of the issuance of any approval, the applicant accepts full
legal responsibility for all damage direct or indirect, of whatever nature, and by whomever suffered, arising out of the project described herein and
agrees to indemnify and save harmless the Town from suits, actions, damages and costs of every name and description resulting from said project.
Signature of Owner Signature of applicant (if different; provide owner’s endorsement)
Date: Date:
Phone (631) 451-6400 Fax (631) 451-6419 Last Revised 02-23-18
www.brookhavenny.gov
Building Area (for commercial projects only): _____________ SF
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AFFIDAVIT-OF-INDEMNITY
INDIVIDUAL
KNOW ALL MEN BY THESE PRESENTS:
That ____________________________________________, as owner of the project property and
hereinafter referred to as Applicant, residing at _________________________________________________,
County of _______________________, State of _________________, for the purpose of obtaining Historic
District Approval pursuant to Chapter 85, Article XVII of the Code of the Town of Brookhaven, having been
duly sworn does hereby depose and say that:
In consideration of the issuance of said Approval, the Applicant does hereby agree to indemnify and save
harmless the Town of Brookhaven, its employees, agents and public officers, against any and all damages to
property or injuries to or death of any person or persons, including property and employees, public officers, or
agents of the Town of Brookhaven, and shall defend, indemnify, and save harmless the Town of Brookhaven,
its employees, agents, and public officers, from any and all claims, demands, suits, actions, or proceedings of
any kind or nature, of or by anyone whomsoever, in any way resulting from or arising out of operations
connected with the issuance of the Approval. This indemnification shall be binding upon any assignees, heirs or
successors in-interest.
Additionally, the applicant does hereby agree to allow employees of the Town of Brookhaven, in conjunction
with this application, to inspect the project site as necessary.
IN WITNESS WHEREOF I have hereto set my hand this ____ day of ____________________ , 20______
_________________________________________
(Owner’s Signature)
STATE OF NEW YORK¬
¬ss.:
COUNTY OF SUFFOLK¬
O
n the ____ day of _________, in the year 20____, before me, the undersigned, a Notary Public in and for said State, 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)
AFFIDAVIT-OF-INDEMNITY
INDIVIDUAL
(Contract Vendee)
KNOW ALL MEN BY THESE PRESENTS:
That ____________________________________________, as the contract vendee of the project
property and hereinafter referred to as Applicant, residing at _______________________________________,
________________, County of _______________________, State of _________________, for the purpose of
obtaining Historic District Approval pursuant to Chapter 85, Article XVII of the Code of the Town of
Brookhaven, having been duly sworn does hereby depose and say that:
In consideration of the issuance of said Approval, the Applicant does hereby agree to indemnify and save
harmless the Town of Brookhaven, its employees, agents and public officers, against any and all damages to
property or injuries to or death of any person or persons, including property and employees, public officers, or
agents of the Town of Brookhaven, and shall defend, indemnify, and save harmless the Town of Brookhaven,
its employees, agents, and public officers, from any and all claims, demands, suits, actions, or proceedings of
any kind or nature, of or by anyone whomsoever, in any way resulting from or arising out of operations
connected with the issuance of the Approval. This indemnification shall be binding upon any assignees, heirs or
successors in-interest.
Additionally, the applicant does hereby agree to allow employees of the Town of Brookhaven, in conjunction
with this application, to inspect the project site as necessary.
IN WITNESS WHEREOF I have hereto set my hand this ____ day of ____________________, 20______
_________________________________________
(Contract Vendee's Signature)
STATE OF NEW YORK¬
¬ss.:
COUNTY OF SUFFOLK¬
O
n the ____ day of _________, in the year 20____, before me, the undersigned, a Notary Public in and for said State, 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)
AFFIDAVIT-OF-INDEMNITY
CORPORATION
KNOW ALL MEN BY THESE PRESENTS:
That _____________________________ hereinafter referred to as Applicant, as a responsible party/officer of
the corporation known as ___________________________________, located at _______________________
_________________________________________________, County of __________________, State of
_________________________, for the purpose of obtaining Historic District Approval pursuant to Chapter 85,
Article XVII of the Code of the Town of Brookhaven, having been duly sworn does hereby depose and say that:
In consideration of the issuance of said approval, the Applicant does hereby agree to indemnify and save
harmless the Town of Brookhaven, its employees, agents and public officers, against any and all damages to
property or injuries to or death of any person or persons, including property and employees, public officers, or
agents of the Town of Brookhaven, and shall defend, indemnify, and save harmless the Town of Brookhaven,
its employees, agents, and public officers, from any and all claims, demands, suits, actions, or proceedings of
any kind or nature, of or by anyone whomsoever in any way resulting from or arising out of operations
connected with the issuance of the Approval. This indemnification shall be binding upon any assignees, heirs or
successors in-interest.
Additionally, the applicant does hereby agree to allow employees of the Town of Brookhaven, in conjunction
with this application, to inspect the project site as necessary.
IN WITNESS WHERE OF I have hereto set my hand this _____ day of ______________________, 20____
_
__________________________________________
(APPLICANT)
STAT
E OF NEW YORK¬
¬ss.:
COUNTY OF SUFFOLK¬
O
n the ____ day of _________, in the year 20____, before me, the undersigned, a Notary Public in and for said State, 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)
TOWN OF BROOKHAVEN BOARD OF ETHICS
TRANSACTIONAL DISCLOSURE FORM
A
PPLICANT NAME: __________________________________________
(LAST NAME, FIRST NAME, M.I)
APPLICANT ADDRESS: ___________________________________________
(STREET, APT.)
___________________________________________
(CITY STATE ZIP CODE)
NATURE OF APPLICATION: (CHECK ALL THAT APPLY)
TAX GRIEVANCE APPROVAL OF PLAT
VARIANCE EXEMPTION FROM PLAT OR OFFICIAL MAP
AMENDMENT LICENSE OR PERMIT
CHANGE OF ZONE OTHER___________________________________
D
OES 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?
YES NO
If you answered “yes”, complete the rest of the form and date and sign where indicated.
If you answered “no”, simply sign and date the form where indicated.
I
NTERESTED PARTY AND NATURE OF INTEREST
:
NAME _______________________________________
A
DDRESS _______________________________________
________________________________________
TI
TLE ________________________________________ DEPARTMENT ____________________________
Relatio
nship to public officer/employee and his or her title if other than self: ________________________________________
I
NTERESTED PARTY:
A)
Is the owner of greater than five percent (5%) of the corporate stock of the applicant when
the applicant is a corporation whose stock is listed on the New York or American Stock Exchange.
YES NO
B)
The act
ual applicant
YES NO
C) An officer, director, partner, or employee of the applicant; or
YES NO
D) Legally or beneficially owns or controls any stock of a non-publicly traded corporate applican
t
or
is a member of a partnership or association of the applicant.
YES NO
DATE___________________
________________________________________
SIGNATURE OF APPLICANT
TOWN OF BROOKHAVEN
OWNERS CONSENT FORM
Date: ______________________
Commissioner of PELM
Town of Brookhaven
Department of Planning, Environmental Protection, & Land Management
1 Independence Hill
Farmingville, NY 11738
RE: Historic District Application for ___________________________
S.C. Tax # of parcel(s) _______________________________________
Dear Commissioner:
Please be advised that I am the owner of record of the above referenced property and hereby consent to
__________________________________________ making an application for HISTORIC DISTRICT
APPROVAL to the Department of Planning, Environmental Protection, & Land Management.
As owner of the property, I understand that I will receive copies of all correspondence unless noted
below. I also acknowledge that as owner, I am responsible for all activities that take place on the property
identified above.
Sincerely,
_________________________________
(Signature, of Owner)
_________________________________
Dated
The applicant is the contract vendee of the property and I do not wish to receive copies of any
correspondence.
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HDAC-Application-Packet-PDF HISTORIC DISTRICT APPLICATION CHECKLIST

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Completed 11 July 2020

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