Town of Brookhaven
Long Island
Department of Building and Fire Prevention
Beth Reilly, Esq., Commissioner
Tara McLaughlin, Deputy Commissioner
Building Division • Angus Graham, Chief Building Inspector
One Independence Hill, Farmingville, NY 11738 • Phone 631-451-6333 • Fax 631-451-6341
Inspection Standards and Certification
To Be Submitted for a Rental Registration When The Owner Elects to Have the Inspection
Performed By a NYS Licensed Engineer, Architect or Home Inspector
Use this form for complexes with greater than 50 dwelling units
This form is to be completed by only a NYS licensed Professional Engineer, a NYS licensed
Registered Architect, or a NYS licensed Home Inspector who also holds a current certification as a
NYS Code Enforcement Official (CEO). This completed form is required to be submitted to the
Town of Brookhaven within ninety (90) days of issuance of the Temporary Rental Registration.
I, ____________________________ , am licensed by NYS as a (check appropriate box)
□ Professional Engineer □ Registered Architect □ Home Inspector
with CEO Certification
license number __________________, and I have performed an inspection of the premises
located at # _______ on the east/west/north/south side of _______________________________
in the hamlet of ______________________________ . That situated on the premises is ______
buildings that contain __________ dwelling units, and that I have inspected all common areas and
common utility areas and further, that I chose at random and performed inspections in at least 20%
of the dwelling units in each building and that I determined there were no violations at the initial
inspection of any of those dwelling units, and as 20% has been determined to be a satisfactory
sampling to determine compliance when no violations are present, I certify that the use, buildings
and structures thereon are in compliance with the Certificate(s) of Occupancy, or its equivalent,
that have been issued for the referenced parcel, and further, that the premises, including buildings
and structures, are in compliance with Town of Brookhaven Code Chapter 82 Section 3, The
Property Maintenance Code of NYS and the Fire Code of NYS. The specific dwelling units
inspected are attached to this document.
Note: Should any violation be determined in any of the dwelling units inspected then all of
the units in the complex are to be inspected.
Date ____________________ Signature ______________________________________
Name (print) ____________________________________
Business Name __________________________________
Address _______________________________________
___________________________
Seal ______________________________________________
