TOWN OF BROOKHAVEN
OWNERS CONSENT FORM
Date: _________________________________
Town of Brookhaven
Division of Environmental Protection
One Independence Hill
Farmingville, New York 11738
RE: Application for a Wetlands & Waterways Permit for ___________________________________________
(Owner’s Name)
SUFFOLK COUNTY Tax # of parcel(s) ____________________________________________________
To whom it may concern:
Please be advised that I am the owner of record for the above referenced property and hereby consent to
_______________________________________ making an application for a WETLANDS & WATERWAYS
(Name of agent or contract vendee)
PERMIT/COASTAL EROSION MANAGEMENT PERMIT to the Division of Environmental Protection.
As owner of the property, I understand that I will receive copies of all correspondence unless noted
below. I also acknowledge that as the owner, I am responsible for all activities that take place on the property
identified above.
Sincerely,
_________________________________
(Signature of Owner)
_________________________________
Date
The applicant is the contract vendee of the property and I do not wish to receive copies of any
correspondence.
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