Fillable Town of Brookhaven Long Island NEW HOUSE INSTRUCTIONS (Town of Brookhaven)

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Town of Brookhaven Long Island NEW HOUSE INSTRUCTIONS (Town of Brookhaven)

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Town of Brookhaven
Long Island
Division of Building 10-11-16
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
www.brookhavenny.gov
NEW HOUSE INSTRUCTIONS FOR OBTAINING A BUILDING PERMIT
(all one-family dwellings excluding the Great South Beach Area)
1. Application for Building and Zoning Permit completely filled out. Plumbing Application completely filled in.
FORMS AVAILABLE ON LINE
2. One original survey indicating preliminary approval by the Suffolk County Health Department as to water supply and sewage
system. Applicants whose property is within 300 feet of tidal or non-tidal waters are referred by the Suffolk County Health
Department to the New York State Department of Environmental Conservation.
3. One original survey that has been approved by the Planning Board and the Department of Environmental Protection as to
compliance with appropriate sections of Chapter 85 (Zoning Ordinance) and the following laws or ordinances:
a. Chapter 33 (Flood Damage Prevention Ordinance)
b. Chapter 35 (Grading Ordinance)
c. Chapter 70 (Tree Preservation Ordinance)
d. Chapter 81 (Wetlands Ordinance)
e. Chapter 98 (Environmental Protection Local Law)
f. Chapter 130 (Subdivision Regulations)
g. Chapter 280A (New York State Law – Permits for
buildings not on improved mapped streets)
4. Transaction Disclosure – complete and sign
5. Three (3) sets of construction plans and a digital copy if available with new Energy Star compliance certificate from HERS rater.
Construction plans must bear the seal of a registered architect or professional engineer, plumbing diagram and HVAC
mechanicals. Please refer to the Residential Drop-Off Plans Checklist for detailed submission requirements.
6. Highway work permits when required from Town, County, or State agencies having jurisdiction over street or road adjacent to
property.
7. Board of Appeals variance in instances where a chain of title is not applicable and where application does not indicate conformity
with Chapter 85 (Zoning Ordinance).
8. Statement of estimated cost for decks and/or swimming pools if fee cannot be determined in accordance with Section 16-5 of
Chapter 16 (Building Construction Administration).
9. Two (2) extra surveys showing proposed residence.
10. Payment of statutory fee.
11. If property is located in Historic District, approval from Historic District Committee is necessary.
12. Wetlands – approval from EPA and/or DEC when required.
13. Workers Compensation & Disability Insurance – The only Certificate of Insurance forms accepted as proof of Workers
Compensation from builder/contractor are: C-105.2 (9-07), SI-12, U-26.3, GSI-105.2, WC/DB-100, and Disability are: WC/DB-
100, db-120.1 or DB-155. The Town of Brookhaven must be named as Certificate Holder. NO ACORD FORMS WILL BE
ACCEPTED. For additional information please call Walter Peretti at NYS WC Board 518-402-8330.
14. Notice of Utilization of Truss Type Construction, Pre-Engineered Wood Construction and/or Timber Construction in Residential
Structures.
___
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
(attached)
□
Accessory Apartment License
□
House Rental License
(supplement appl. needed)
□
Letter of
Correction
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):
Owner Certification
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
accuracy.
Owner Print Name Signature Date
OR
Agent Authorization
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
of
}
:
ss
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
New construction must have a plumber’s signature.
Owner’s signature is acceptable only for an existing residential
Dwelling where the owner is doing the plumbing work. 1-2019
Plumbing HVAC Worksheet
Building Permit #: ___________ Date of Permit: __________Residential________Commercial: _________Worksheet Date:_________
Location of Building: _________________________________________ Section: ___________ Block: ___________ Lot: ____________
Owner Name: _____________________________________ Address: _______________________________________________________
Basement
1
st
Floor
2
nd
Floor
3
rd
Floor
Other
Fee
Total Units
Air Handlers
Blowers/Boilers/Space Heaters/Furnace
Central A. C.
Bath Tubs
Showers
(Floor) Drains
(Roof) Drains
Hand Sink
Kitchen Sinks
Lavatories (Bathroom Sinks)
Stacks (Number Of) Residential
Stacks (Number Of) Commercial
Urinals
Water Closets (Toilets)
Dishwasher
Drinking Fountain
Hot Water Supply – Oil/Gas Tank-less
Hydronic Solar Collectors
Indirect Waste
In-ground Tank Installation
Lawn Sprinklers
Outlet (Future)
Outside Hose Bibs
Utility Sinks/Laundry Tubs
Washing Machines
Other ( )
Other ( )
Total Fees:
Town of Brookhaven
Building Division
One Independence Hill, Farmingville
NY 11738 • Phone 631-451-6333 • Fax 631-451-6341
Plumbing Business Name: __________________________________
Business Address: _________________________________________
Telephone Number __________________________
Suffolk County Consumer Affairs License ______________________
Expiration Date: _____________________
Plumbing work is being done by:
Owner Signature_________________________________
Agent Signature__________________________________
OR
________Licensed Plumber
Signature ________________________________________
Printed Name_____________________________________
________________________________________
Notary Signature
Effective
TOWN OF BROOKHAVEN
TRANSACTIONAL DISCLOSURE FORM
(Conflict of Interest Form)
A Transactional Disclosure form is required when someone submits certain applications to
Brookhaven Town. The purpose of the disclosure is to alert the Town if a party of influence
has an interest in this application or if someone within the Town who will participate in the
decision has an interest.
*Note: It is required that a copy of this form be sent to the Director of the Board of Ethics.
Name______________________________Address___________________________
City ______________________________________ State ____ Zip _________
Telephone ____________________ Email _______________ Fax ________________
This form is for:
 An individual  A partnership
 A corporation  An association
Nature of Application:
 Property Assessment Grievance for non-residential parcel  Variance
 Amendment  Change of Zone
 Approval of Plat  Exemption from Plat or Official Map
 License or Permit affecting real property  Bidding on contract(s)
Affected parcel (address) ______________________________________________________
Does any officer or employee of the Town of Brookhaven, member of an executive
committee of a political party, or his/her spouse, brother, sister, parent, child, grandchild or
spouse of any of them, have an interest in this application by virtue of being the actual
applicant, being the owner of the actual property or having an interest in the corporation,
partnership or association making such application? Yes ____ No ____
If Yes, complete the appropriate section below.
If No, sign and date at end of form.
Please complete the following relevant section below:
For individual:
Interested Party:
Name______________________________Address ___________________________
City ______________________________________ State ____ Zip _________
Page 1 of 2 Effective 5/15/2018
For corporation:
Interested Party:
Name______________________________Address ___________________________
City ______________________________________ State ____ Zip _________
Title _________________________ Department ____________________________
Relationship to Public Officer/Employee and Title, if other than Self: ________________
Yes ___ No ___ Is the owner of greater than five percent (5%) of the corporate
stock of the application when the applicant is a corporation whose
stock is publicly traded.
Yes ___ No ___ The actual applicant,
Yes ___ No ___ An Officer, Director, Partner, or Employee of the applicant, or
Yes ___ No ___ Legally or beneficially owns or controls any stock of a non-
publicly traded corporate applicant or is a member of a partnership
or association of the applicant.
For partnership or association:
Interested Party:
Name______________________________Address ___________________________
City ______________________________________ State ____ Zip _________
Title _________________________ Department ____________________________
Relationship to Public Officer/Employee and Title, if other than Self: ________________
Yes ___ No ___ Does the owner hold greater than five percent (5%) interest of publicly
traded shares?
Yes ___ No ___ The actual applicant,
Yes ___ No ___ An Officer, Director, Partner, or Employee of the applicant, or
Yes ___ No ___ Legally or beneficially owns or controls any stock of a non-
publicly traded corporate applicant or is a member of a partnership
or association of the applicant.
ALL APPLICANTS PLEASE FILL OUT BELOW:
Print Name _____________________________________ Date ________________
Signature ___________________________________________
Page 2 of 2 Effective 5/15/2018
Town of Brookhaven
Long Island
NOTICE OF UTILIZATION OF TRUSS TYPE CONSTRUCTION,
PRE-ENGINEERED WOOD CONSTRUCTION AND/OR TIMBER
CONSTRUCTION IN RESIDENTIAL STRUCTURES
(In accordance with Title 19 NYCRR PART 1265)
OWNEROFPROPERTY:
SUBJECTPROPERTY(ADDRESSANDTAXMAPNUMBER):



PLEASETAKENOTICETHATTHE(CHECKALLTHATAPPLY):
NewResidentialStructure
AdditiontoExistingReside ntialStructure
RehabilitationtoExistingResidentialStructure
TOBECONSTRUCTEDORPERFORMEDATTHESUBJECTPROPERTYREFERENCEABOVEWILLUTILIZE
(checkeachapplicableline):
TrussTypeConstruction(TT)
Pre‐EngineeredWoodConstruction(PW)
TimberConstruction(TC)
INTHEFOLLOWINGLOCATION(S)(CHECKAPPLICABLELINE):
FloorFraming,IncludingGirdersandBeams(F)
RoofFraming(R)
FloorFramingandRoofFraming(FR)
SIGNATURE: DATE:
PRINTNAME:
CAPACITY(CheckOne): Owner Owner’sRepresentative
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Town of Brookhaven Long Island NEW HOUSE INSTRUCTIONS (Town of Brookhaven)

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Completed 2 August 2020

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