Fillable Rental Permit PDF (Town of Brookhaven)

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Rental Permit PDF (Town of Brookhaven)

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Town of Brookhaven
Long Island
Division of Building 1-2019
Tullio Bertoli, AICP, 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
RENTAL REGISTRATION PERMIT REQUIREMENT
Note: This form is to be used for New Rental Registrations Only. Please Use the Rental Registration Renewal form to renew your
existing registration.
ALL FORMS MUST INCLUDE OWNER OR AGENTS PHYSICAL ADDRESS—NO P.O. BOX NUMBERS WILL BE
ACCEPTED
1. BUILDING PERMIT APPLICATION—completed and signed by OWNER, MANAGING AGENT, OR DWELLING
OPERATOR
2. RENTAL REGISTRATION FORM—completed and signed by one of those listed in #1 above. The form must be
notarized.
3. DISCLOSURE AFFIDAVIT—completed and signed by applicant.
4. CERTIFICATION OF STRUCTURES FORM
5. FEES—a non-refundable permit application fee payable upon filing an application in accordance with the following
schedule of rental dwelling units per structure:
ONE-FAMILY DWELLING FEE ONE-FAMILY DWELLING FEE
One (1) bedroom $95 Two (2) bedrooms $160
Three (3) bedrooms $220 Four (4) bedrooms $285
More than 4 bedrooms $345 base fee (plus $100 for each bedroom in excess of 4)
MULTI-UNIT APARTMENT COMPLEXES FEE MULTI-UNIT APARTMENT COMPLEXES FEE
4 to 50 units $1,000 51 to 100 units $1,500
101 to 200 units $2,500 Over 200 units $5,000
6. FOUR (4) COPIES OF A SURVEY OF THE PREMISES—drawn to scale not greater than forty (40) feet to one inch, or,
if not shown on the survey, a site plan, drawn to scale, showing all buildings, structures, walks, driveways and other physical
features of the premises and the number, location and access of existing and proposed on-site vehicle parking facilities.
Surveys must be complete and legible, include the surveyor’s seal, survey date/or revision date and the distance from the
nearest tie street. Condominiums without surveys require a certified copy of the deed.
7. THREE (3) COPIES OF THE FLOOR PLAN OF EACH RENTAL DWELLING UNIT—Plans are to be drawn with
a straight edge in scale, include all floor levels and basement, be neat, accurate and include dimensions and uses of all rooms,
hallways, foyers, and other spaces; window type and sizes for sleeping rooms; door dimensions, location of smoke detectors
and carbon monoxide alarms. The exterior outline and dimensions of the floor plans are to match the property survey.
8. ONE (1) PHOTOCOPY OF ALL CERTIFICATES OF:
OCCUPANCY (CO) EXISTING USE (CEU) PREVIOUS RENTAL LICENSES
COMPLIANCE (CC) ZONING COMPLIANCE (CZC)
9. Upon the filing of a Rental Registration application a Temporary Rental Registration will be issued. The Temporary
Rental Registration expires ninety (90) days from issuance. Within ninety (90) days of the issuance of the Temporary
Rental Registration the owner/applicant of the rental dwelling unit shall arrange for an inspection of the unit or units
and the premises on which the same are located by; (1) the Town of Brookhaven Building Division, or (2) provide to the
Chief Building Inspector an Inspection Report signed by either a NYS licensed Professional Engineer, a NYS licensed
Registered Architect, or a NYS licensed Home Inspector who also holds a current NYS Code Enforcement Official
Certification, certifies the structure and the dwelling units contained therein meet all applicable housing, sanitary, building,
electrical and fire codes, rules and regulations, including Town of Brookhaven Town Code Chapters 82 (Neighborhood
Preservation Requirements) and Chapter 85, and The Property Maintenance Code of NYS and The Fire Code of NYS.
When within the ninety (90) days in which the Temporary Rental Registration is valid that there occurs approval of the
inspection standards by a Town of Brookhaven Building Inspector or proof of approval of the inspection standards by
the NYS licensed professional referenced above. The Chief Building Inspector will issue for dwelling units located in a one,
two, or three family dwelling a Provisional House Rental License valid for 15 months from the date of issuance of the
Temporary Rental Registration, and for multi-unit apartment complexes a Provisional House Rental License valid for 2
Town of Brookhaven
Long Island
Division of Building 1-2019
Tullio Bertoli, AICP, 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
years from the date of issuance of the Temporary Rental Registration.
___
Town of Brookhaven
Long Island
Building Permit Application
APPLICATION is hereby made for a permit to do the following work, which will be done in accordance with the description, survey and plans submitted pursuant to
Section 57 of the Worker’s Compensation Law, Zoning Ordinances, Building Code and all other applicable ordinances and laws. Article 15 of the Executive Law of the
State of New York, Section 296-5 (A) (1) prohibits discrimination in the sale, rental or lease of housing accommodations because of race, creed, color or national origin.
Select All That Apply
□
Residential Building Permit
□
Commercial Building Permit
□
Record Search
□
Certificate of Existing Use
Plumbing Work Form
□
Accessory Apartment License
□
House Rental License
(supplement appl. needed)
□
Letter of
Correction
□
Renewal of permit/license#
Property Suffolk County Tax Map Number - District 0200 Section Block Lot(s)
Property Owner Name Phone eMail
Property Owner Current Address: Zip
Authorized Agent/Attorney Name Phone eMail
Authorized Agent/Attorney Address
Property located at No. N.S.E.W. side Distance
N.S.E.W. of Town NY
Description/ Request/Use/Size of proposed work
Project Name (if applicable):
Owner Certification
I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the above information and certify its
accuracy.
Owner Print Name Signature Date
OR
Agent Authorization
I hereby authorize to act as my agent(s) to apply for, sign, and file the documents
necessary to obtain a Building Permit / License for the project, as described above. Note: A copy of the owner’s driver’s license, form notarization, or
other verification acceptable to the agency is required to be presented when the permit is issued to verify the property owner’s signature.
County
of
}
:
ss
State of New York Owner Print Name Signature
On the day of in the year before me, the undersigned, 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 Public State of New York
Print Name Signature
Commission Number Expiration Date
Building Division • Phone 631-451-6333 • Fax 631-451-6341
Each application must be typewritten or printed and have all information answered. Incomplete or illegible applications will not be accepted.
B_APPLICATION Rev. 05/13
RENTAL REGISTRATION APPLICATION
NON-OWNER OCCUPIED DWELLINGS
NOT INCLUDING FIRE ISLAND
1. PROPERTY INFORMATION
a. Street Address Location ______________________________________________________
___________________________________________________________________________
b. Tax Map Number 0200 - ____________ - ____________ - ____________
2. OWNER’S INFORMATION
a. Name
___________________________________________________________________________
(Print)
b. Address (No Post Office Box):
_______________________________________________________________________________
(Number) (Street) (City) (State) (Zip)
c. Telephone Number _______________ __________________________________________
(Area Code) (Home Number)
_________________________________________________________
(Area Code) (Work Number)
d. E-Mail Address _____________________________________________________________
3. APPLICANT INFORMATION
a. Check if applicant is: _____ Owner _____ Operator _____ Agent
b. Name: _________________________________________________________________
c. Address of Operator or Agent: (No Post Office Box):
_______________________________________________________________________
(Number) (Street) (City) (State) (Zip)
4. ALTERNATE CONTACT FOR EMERGENCIES
Owners who reside further than 25 miles outside the Town of Brookhaven, must designate an alternate
contact who will respond to calls from Police, Fire, Emergency or Town Inspections personnel when
attempts to contact the owner/agent have failed, the owner is unavailable to respond in a timely manner
or the owner is unable to be physically present at the residence when required by above noted entities.
The designated alternate contact person must be located in the Town of Brookhaven or within twenty-
five (25) miles of the Town of Brookhaven.
a. Name _________________________________________________________________
(Print)
b. Address (No Post Office Box):
_______________________________________________________________________
(Number) (Street) (City) (State) (Zip)
Page 1 1-2019
c. Telephone Number ______________________________________________________
(Area Code) (Home Number)
______________________________________________________
(Area Code) (Work or Mobile Number)
d. E-Mail Address _____________________________________________________
5. FILL OUT THIS SECTION IF RENTAL UNIT IS A HOUSE, CONDO OR CO-OP
TYPE OF DWELLING check one: ____House ____Condo ____Co-op
Occupancy, Bedroom /50 sqft., divide by 50 sqft. Per person
(Minimum bedroom size limited to 70 sqft.)
1. Bed_____________sqft. Number of Persons________
2. Bed_____________sqft. Number of Persons________
3. Bed_____________sqft. Number of Persons________
4. Bed_____________sqft. ` Number of Persons________
5. Bed_____________sqft. Number of Persons________
6. Bed_____________sqft. Number of Persons________
Sub total ________
Living Room________sqft.
_____<120 sqft, Insufficient
_____>120 sqft., 1-5 persons.
_____>150 sqft., 6 or more persons
Dining Room________sqft.
_____ < 80 sqft., 1-2 persons.
_____ > 80 sqft., 3-5 persons.
______> 100 sqft., 6 or more persons.
Liv/Din Combo Room.__________sqft.
(one large dual-purpose room)
____ < 120 sqft, Insufficient
____ > 120 sqft., 1-2 persons.
____ > 200 sqft., 3-5 persons.
____ > 250 sqft., 6 or more persons.
Max Occupancy per 2015 IPMC, section 404. _______persons.
FOR OFFICE USE ONLY
FEE:
One (1) Bdrm. $95.00
Two (2) Bdrms. $160.00
Three (3) Bdrms. $220.00
Four (4) Bdrms. $285.00
More than 4 $345.00
Plus $100.00 for each bedroom in excess of 4
TOTAL FEE ____________________ Page 2 1-2019
6. FILL OUT THIS SECTION IF RENTAL UNIT IS A MULTI-UNIT COMPLEX
Building #__________ Apartment #_________ Unit Model ____________________
CALCULATIONS for HABITABLE ROOMS
Occupancy, Bedroom sqft. Divide by 50 sqft. Per person.
(Minimum bedroom size limited to 70 sqft.)
1. Bed_____________sqft. Number of Persons________
2. Bed_____________sqft. Number of Persons________
3. Bed_____________sqft. Number of Persons________
4. Bed_____________sqft. Number of Persons________
5. Bed_____________sqft. Number of Persons________
6. Bed_____________sqft. Number of Persons________
Sub Total ________
Living Room________sqft.
____ < 120 sqft., Insufficient
____ > 120 sqft., 1-5 persons.
____ > 150 sqft., 6 or more persons
Dining Room________sqft.
____ < 80 sqft., 1-2 persons.
____ > 80 sqft,, 3-5 persons.
____ > 100 sqft., 6 or more persons.
Liv/Din Combo Rooms__________sqft.
(One large dual-purpose room)
____< 120 sqft., Insufficient
____ > 120 sqft., 1-2 persons.
____ > 200 sqft., 3-5 persons.
____ > 250 sqft., 6 or more persons.
Max Occupancy per 2015 IPMC, section 404. _______persons.
FOR OFFICE USE ONLY
Total Number of Units ____________ Total Number of Buildings____________
Duplicate the above Section 6 for each different type of rental unit.
FEE:
4 to 50 Units $1,000.00
51 to 100 Units $1,500.00
101 to 200 Units $2,500.00
Over 200 Units $5,000.00
TOTAL FEE __________________
NOTE: It shall be unlawful and a violation of Chapter 82 for any person or entity who owns a
rental dwelling unit in the Town of Brookhaven to allow more than four (4) persons per bedroom
in said rental dwelling unit.
Page 3 1-2019
7. TOTAL USABLE FLOOR AREA OF HABITABLE ROOMS: _____________________
(Do not include cellar, kitchen or bathroom space. Do not include basement space unless, in addition
to the other provisions of Chapter 82 (Town of Brookhaven Code) and the New York State Uniform
Fire Prevention and Building Code: leakage, runoff and dampness requirements are met; minimum
aggregate glass area of windows (above grade) is satisfied; and the basement space complies in all
respects with the New York State Uniform Fire Prevention and Building Code. Please refer to Chapter
82-7, C. (T. O. B. Code attached) for ceiling height requirements.)
8. Do you have/will you be adding, any additional bedrooms to the/any rental dwelling unit?
(Any additions of bedrooms to a rental dwelling unit shall require Suffolk County Health Department
approval unless an existing Certificate of Occupancy specifically covers such.)
_______
9. Does/Do the/all rental dwelling unit(s) have a dining area and recreation area in the dwelling
structure? _______
10. Was the dwelling unit(s) built prior to 1937? _______
(Refer to Section 82-7, C. and G. for structures built prior to 1937.)
11. Is this dwelling unit a residential care facility established under Federal, New York
State or Suffolk County guidelines or is it utilized by occupants that are in an
established care program?
_______
12. Is the applicant is a not-for-profit housing development corporation organized under the laws of
the State of New York, and is providing housing for senior citizens or other designated special
populations subject to income guidelines established by either federal or state regulation?
_______
13. The owner and the alternate are required to maintain a current list of the dwelling’ occupants.
Upon request by Town Inspectors, Police, Fire or other emergency personnel, the owner or
Alternate is required to present the list of occupants.
Additionally, owners are required to list the names of tenants on all submitted rental applications.
When there is/are no tenant(s) identified at the time of the rental application, an owner must submit an
Updated tenant list to the Town within 15 days of rental property occupancy by tenants. An updated
list must be submitted within 15 days each time a new tenant is added or an existing tenant vacates the
premises.
Designate if: □ Tenant Information Attached □ Tenant Information To Be Submitted
The Town of Brookhaven reserves the right to submit information from rental applications to
the Internal Revenue Service and/or the New York State Department of Taxation and Finance.
Page 4 1-2019
STATE OF NEW YORK )
SS:
COUNTY OF SUFFOLK )
_______________________________________________________ being duly sworn, deposes and says
OWNERS NAME (Line #1 Above, Print)
that he/she reside(s) at __________________________________________________________________
in the Town of ________________________________, in the County of __________________________
and the State of _______________________________, and that he/she is/are the owner(s) in fee of the
premises described in the foregoing petition and that he has/have read the foregoing application and
know(s) the contents thereof; that the same is true to his/her/their knowledge; and that he make(s) the
foregoing petition for a permit for Temporary Rental Registration and further that I/we will comply with
all New York State Building Code Requirements and Town of Brookhaven Requirements pertaining to
Rental Registration and will meet these standards within ninety (90) days of the granting of the
Temporary Rental Registration or the permit will become null and void. I further state that I have
received a copy of and fully understand the Brookhaven Town Code concerning the restrictions on the
number of unrelated persons occupying said residence.
___________________________________________
Signature
___________________________________________
Signature
Sworn to be me this __________________
Day of ________________________, 20
____________________________________
Notary Public
Page 5 1-2019
.
The following persons are tenants residing at the property for which this application is
for identified as ___________________________________________________________.
(Address)
Name (Please Print)
1. _______________________________________________________________________________
2. ________________________________________________________________________________
3. ________________________________________________________________________________
4. ________________________________________________________________________________
5. ________________________________________________________________________________
6. ________________________________________________________________________________
7. ________________________________________________________________________________
8. ________________________________________________________________________________
9. ________________________________________________________________________________
10. ________________________________________________________________________________
Page 6 1-2019
The following excerpts of Town Code regulate the use of a dwelling unit.
Chapter 85-1 Definitions FAMILY
[Amended 7-22-2003, effective 8-11-2003; 8-28-2012 by L.L. No. 21-2012,
effective 9-11-2012]
(1) The following groups shall be considered a family:
(a) Any number of persons related by blood, marriage, legal adoption or legal foster relationship, living
and cooking together as a single, nonprofit housekeeping unit;
(b) Four or more persons occupying a single dwelling unit and living together as a traditional family or the
functional equivalent of a traditional family.
(2) It shall be presumed that four or more persons living in a single nonprofit dwelling who are not related
by blood, marriage, legal adoption or legal foster relationship do not constitute the functional
equivalent of a traditional family. This presumption can be overcome only by a showing that, under
the standards enumerated in Subsection C hereof, the group constitutes the functional equivalent of a
traditional family. A determination as to the status of such group may be made in the first instance by
the Chief Building Inspector or his designee, or on appeal from an order, requirement, decision or
determination made by him, by the Zoning Board of Appeals in conformance with this Chapter 85 of
the Brookhaven Town Code.
(3) In determining whether four or more persons living in a single nonprofit dwelling who are not related
by blood, marriage, legal adoption or legal foster relationship constitute the functional equivalent of a
traditional family pursuant to Subsection A(2), the following factors shall be evaluated:
(a) The group is one which lives and cooks together as a single housekeeping unit, shares expenses for
food, rent, ownership costs, utilities and other household expenses. A unit in which the various
occupants act as separate roomers may not be deemed to be occupied by the functional equivalent
of a traditional family.
(b) The group is of a permanent and stable nature and is neither a framework for transient or seasonal
living nor merely an association or relationship which is transient or seasonal in nature. Nothing
herein shall preclude the seasonal use of a dwelling unit by a group which otherwise meets the
standards of this subsection at its permanent residence. Evidence of such permanence and stability
includes, but is not limited to:
[1] The presence of minor children regularly residing in the household who are enrolled in a local school.
[2] Members of the household have the same address for the purposes of voter registration, drivers'
licenses, motor vehicle registration, filing of taxes and delivery of mail.
[3] Members of the household are employed in the area.
[4] The household has been living together as a unit for a year or more, whether in the current dwelling or
in other dwelling units.
[5] The existence of a head of the household that cares for the occupants in a family-like living
arrangement.
[6] Common ownership of furniture and appliances among the members of the household.
[7] Any other factors reasonably related to whether or not the occupants are the functional equivalent of a
family.
(4) All other requirements of this chapter regarding the use and occupancy of a residence for one family
shall be complied with.
(5) Any determination under this subsection shall be limited to the status of a particular group of persons
as a family and shall not be interpreted as authorizing any other use, occupancy or activity.
(6) In no case shall a residence for a single family be occupied by more than the number of persons
permitted under the standards presented in this chapter.
(7) Floor plans of the dwelling unit shall be submitted to the Chief Building Inspector or his designee, and
on appeal if necessary to the Zoning Board of Appeals, and must conform to all Town and state laws,
regulations and codes.
(8) There shall be at least one room which is not designed as a conventional bedroom, bathroom, foyer,
storage area or closet.
(9) The Chief Building Inspector, or his designee, or the Zoning Board of Appeals may impose such conditions and
safeguards as it shall deem reasonable, necessary and/or advisable in order to maintain the stability and
character of the neighborhood and protect the health, safety and welfare of the community.
Town of Brookhaven
Long
Island
Certification of Structures 3-2019
Must be completed by the owner for: *
Suffolk County Tax Map Number: 0200 _______/ /
Item Number: _____________
*Suffolk County Tax Map Number and Item Number can be found
on your Tax Bill
Please check below all structures or improvements currently located on the property. In order to receive a Certificate
of
Occupancy or equivalent for the proposed work all structures and/or improvements must be certified by the
Town of
Brookhaven.
Office Use Only
Primary Structure (e.g. main house)
Detached Garage
Garage Conversion
Barn
Apartment
Swimming Pool/Hot Tub
Greenhouse
Finished Basement
Outside Basement Entrance
Fireplace(s)
Porches/Screened Porches
Wood Platforms/Ramps
Fence(s)
Gazebo(s) How many?
Shed(s) How many?
Deck
Addition
Modification
Other
Covenants or Restrictions such as
Clearing Limits or Natural Buffers
Sports Court
Outdoor BBQ area/Outdoor Kitchen
I do hereby certify that all statements made by me in this certification of structures are true and correct to the best of my
knowledge, information and belief, further, I understand that in the event that I have knowingly and willfully made any
false statements, I will be liable for punishment in accordance with all applicable laws and statutes.
Owner Name: (Print) Date:
Signature:
Physical Property Address:
Mailing Address, if different:
Phone Number:
Email Address:
Building Division www.brookhavenny.gov
One Independence Hill, Farmingville, NY 11738 · Phone 631-451-6333 · Fax 631-451-6341
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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