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