Town of Brookhaven
Long Island
Division of Building
Beth Reilly, Esq., Commissioner
Tara McLaughlin, Deputy Commissioner
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
This form is to be completed by only a NYS licensed Professional Engineer, or a NYS licensed
Registered Architect, or a NYS licensed Home Inspector who also holds a current certification as a
NYS Code Enforcement Official. 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 ______________________________ . 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.
Date ____________________ Signature ______________________________________
Name (print) ____________________________________
Business Name __________________________________
Address _______________________________________
___________________________
Seal ______________________________________________
Contact # _____________________________________________
Rental Registration Number __________________ 05/16
