Fillable Long Island Town of Brookhaven CERTIFICATE OF EXISTING (Town of Brookhaven)

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Long Island Town of Brookhaven CERTIFICATE OF EXISTING (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
One Independence Hill, Farmingville, NY 11738 • Phone 631-451-6333 • Fax 631-451-6341
www.brookhavenny.gov
CERTIFICATE OF EXISTING USE
Mainland
Certificates of Existing Use are issued for structures for which there are NO RECORD at the Town of Brookhaven.
THE FOLLOWING IS REQUIRED:
1. Application for Certificate of Existing Use.
2. Owner’s Affidavit…completed, signed by owner(s) only and notarized.
3. Disclosure Affidavit…completed and signed by owner(s) only.
4. Copies of all other Certificates of Occupancy and/or Building Permits.
5. One (1) original survey, this means the survey will show everything that is on the property as of today.
Photocopies will NOT be accepted.
6. If owner is deceased – a copy of the Letters Testamentary is required.
7. Proof that the structure(s) existed prior to the relevant date below.
8. Photographs of all sides of all structures on the property.
SINGLE FAMILY DWELLING: You may apply for this certificate by submitting legal proof that the structure was
constructed prior to June 30, 1959.
TWO FAMILY DWELLING: This certificate requires approval from the Board of Zoning Appeals. This office
will provide you with the applicable date for the legal proof requirement.
COMMERCIAL BUILDING: You may apply for this certificate by submitting legal proof that the premises were
improved prior to 1959. This certificate may require a variance from the Board of Zoning Appeals.
PROOF MAY BE ONE OR MORE OF THE FOLLOWING: - PROOF MUST BE CONCLUSIVE.
A) Certified Tax Search showing the buildings only being assessed on the property prior to applicable
date(s) as stated above.
B) Original survey dated prior to the applicable date(s) as stated above.
C) Original New York Board of Fire Underwriters Certificate prior to the applicable date as stated above.
(Buildings only)
D) Other proof (i.e. Certificate of Occupancy for an addition to the structure; deed that specifically
identifies the buildings on the property; newspaper articles; developer dated photographs) – all dated
prior to the applicable date and approved by the Town of Brookhaven.
Residential fee is $132.48. Commercial fee is $198.92. Fees are payable to the Town of Brookhaven by money
order, check, or cash payment in person. Applications are accepted between the hours of 9:00 a.m. and 4:00 p.m.,
Monday through Friday.
1-2020
Town of Brookhaven
Certificate of Existing Use Application
Suffolk County Tax Map Number: _ _ _ _-_ _ _ _ _-_ _ _ _- _ _ _ _ _ _
Building/House Number: __________ N S E W side of: ________________________
Distance: _______________________ N S E W of: __________________________________
Hamlet: _____________________________, State of New York
The Certificate of Existing Use is requested for the following structures:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Comments:
_____________________________________________________________________________________
_____________________________________________________________________________________
Owner’s Name: ________________________________ Owners Email: __________________________
Owners Mailing Address: _______________________________________________________________
Owners Phone: (H)____________________W)____________________(C)_______________________
Agent Name: __________________________________ Agent Email: ___________________________
Agent Mailing Address: ________________________________________________________________
Agent Phone: (W)____________________(C)____________________
Office Use Only
Researched By: __________
Certificates Found:
_____________________________________________________________________________________
_____________________________________________________________________________________
Zone: __________ Single & Separate: ________________
12/2015
STATE OF NEW YORK }
OWNER’S AFFIDAVIT IN
} SS. SUPPORT FOR A CERTIFICATE
COUNTY OF SUFFOLK } OF EXISTING USE
I,
, being duly sworn, hereby submit the following in support of
this application for a Certificate of Existing Use. The certificate is requested for the following: (structure
and size)
1. The property is located at #
N S E W side of
Distance
N S E W of
Hamlet
.
Suffolk County Tax Map: Section Block Lot(s)
2. The subject parcel of land consists of approximately
square feet.
3. The following uses and structures exist on the subject premises. Check ALL that apply.
Structures (#) Uses (described)
One Family Dwelling
Two Family Dwelling
Detached Garage
Barn
Shed
Business
Other
Other
Other
4. The following uses and structures were added after 1959 or applicable date:
. If none, so state:
5. Was the use of the subject premises discontinued for a period of one year or more?
Yes
No If yes, explain:
6. Do you currently own any parcels of land adjacent to the premises as shown on the survey
submitted with this application?
Yes
No If yes, explain:
7. Have you ever owned any parcels of land adjacent to the premises as shown on the survey
submitted with this application?
Yes
No If yes, explain:
8. Has said parcel been reduced in lot area? Yes
No If yes, state the
year reduced and explain how reduced
I understand that I am executing a legal document and that providing false information will result in rejection of
this affidavit and potential prosecution for perjury.
Signature
Personally appeared before me the above named personally known to me,
who being duly sworn, deposes and says that he/she executed the above instrument and that the statement and
answers contained therein are true and correct to the best of his/her knowledge and belief.
Subscribed and sworn to before me this
day of ,20________.
7-2006 (Notary Public)
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
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Long Island Town of Brookhaven CERTIFICATE OF EXISTING (Town of Brookhaven)

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Completed 2 August 2020

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