Noise Variance Application
Pursuant to Chapter 50-8
PS-01
rev. 4/04
Department of Public Safety
One Independence Hill, Farmingville, NY 11738
(631) 451-6161 FAX (631) 451-6908
DATE:
1. APPLICANT’S NAME:
2. ADDRESS:
3. DAYTIME TELEPHONE:
4. PROPERTY LOCATION:
5. OWNER OF PROPERTY:
(If applicant is other than property owner, consent of owner must be supplied)
6. REASON FOR VARIANCE:
7. PROPOSED NOISE SOURCE:
8. LOCATION OF NOISE SOURCE:
9. MITIGATING FACTORS:
10. DATES FOR REQUESTED VARIANCE:
11. HOURS:
12. ATTACHMENTS AND FEES:
IF CONTRACTOR, ATTACH COPY OF BUILDING PERMIT
IS PROPERTY PART OF A SUBDIVISION? Yes No (If yes, attach copy of building permit and map)
IF PRIVATE HOMEOWNER, ATTACH COPY OF BUILDING PERMIT WHERE APPLICABLE OR ATTACH PROOF
OF OWNERSHIP (copy of tax bill or deed)
A $125 Residential Fee or a $500 Commercial fee. (cash or check made payable to the Town of Brookhaven)
IS REQUIRED AT TIME OF APPLICATION FOR PERMIT
12. APPLICANT’S SIGNATURE:
COMMISSIONER’S SIGNATURE:
P L E A S E T Y P E O R P R I N T C L E A R L Y
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