Town of Brookhaven Complaint Form
COMMERCIAL AND FIRE ISLAND ONLY
BUILDING DIVISION
One Independence Hill
Farmingville, NY 11738
Phone 631-451-6333
Use this form to report a violation of either Town Codes or the NYS Building Codes. Please type or print
legibly. Return this form to the Building Division, you may include supporting documentation. Be sure to
provide your contact information and signature.
TAX MAP NUMBER: 0200 - ______________ - _____________ - ______________
Violation Address:
Street Number: ____________________ Street Name: ____________________________________________
Hamlet: __________________________________ Town of Brookhaven, NY ZIP Code: _______________
Closest Cross Street: __________________________________________________________________________
Violator’s Name: _____________________________________________________________________________
Brief Description of Complaint: ________________________________________________________________
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Previous Complaint Made: NO YES If yes date: __________ Homeowner occupied: YES NO
Requested By:
Name: _____________________________________________
Address: ___________________________________________
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Signature: ________________________________________________________________ Date: ________________
Phone Number(s):
Home: __________________________
Work: __________________________
Cell: ____________________________
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I affirm that all information provided in this complaint is true and factual.
False statements made herein are punishable as a Class “A” misdemeanor pursuant to Section 210.45 of the Penal Law.
Building Division Office Use Only
Item Number: ______________ Violation Number: ________________
Nature of Complaint: _______________________________________________________________________
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11/2014_____________________________________________________________________________________
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