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
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):
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
Owner Print Name Signature Date
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
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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
