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
Existing Construction Affidavit (Form Available on Line)
STATE OF NEW YORK}
SS:
COUNTY OF SUFFOLK}
I_________________________, being duly sworn, depose and state that the
(Owner)
existing ________________________________________________________________
(name or description of structure)
located at Number________ on the N S E W side of ___________________, at a
distance of _________________ N S E W side of ______________________, Tax
Map Number: __ __ __ __-__ __ __.__ __-__ __.__ __-__ __ __.__ __ __,
was constructed on or about _________________________.
(date of construction)
I understand that the above information will be used to determine applicable codes in the
review of my building plans and permit application.
I have submitted the attached documentation to support the above statement.
I am unable to submit documentation to support the above statement due to the
following:
The construction referenced above predates my ownership.
Documentation is not available.
_________________________________
(Signature of Affiant)
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________.
__________________________________________________
(Notary Public)
