Fillable Town of Brookhaven Long Island SIGN PERMIT CHECKLIST (Town of Brookhaven)

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Town of Brookhaven Long Island SIGN PERMIT CHECKLIST (Town of Brookhaven)

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Town of Brookhaven
Long Island
Building Division
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
SIGN PERMIT CHECKLIST
Building Permit Application - Filled out completely and signed.
One (1) Copy of a Recent Property Tax Statement.
One (1) copy of a Property Survey or Site Plan indicating where the sign(s) will be placed.
For Detached Ground Signs – Indicate setbacks the distance from the property line to the edge of the sign(s).
One (1) copy of all Certificates of Occupancy or Certificates of Compliance for the business the sign will
advertise.
Workers Compensation and Disability Insurance for the sign contractor. The only Certificates of Insurance
forms accepted are: Workers Compensation: C-105.2, SI-12, U-26.3, GSI-12, WC/DB-100, WC/DB-101 and
Disability are: DB-120.1, DB-155. The Town of Brookhaven must be named as a Certificate Holder. NO ACORD
FORMS WILL BE ACCEPTED. For additional information please call Walter Peretti at NYS WC Board 518-
402-8330.
Transactional Disclosure Affidavit – Filled out completely and signed on back.
Two (2) copies of professional, detailed, dimensioned Plans of the sign(s).
For WALL SIGNS, elevations of the building showing the height of the sign(s) at the highest point above grade and
the width of store on the wall which the sign is to be placed.
For DETACHED GROUND SIGNS, give the distance from the grade to the top of the highest point of the sign.
Also note that sealed construction plans by a design professional are required for detached ground signs which have
concrete foundations and/or structural steel supports.
DETACHED GROUND SIGNS ONLY
SPEED LIMITS of roadway(s) must be obtained from Traffic Safety 451-6480 for detached ground signs.
One (1) Construction Cost Estimate is required for detached ground signs which have concrete foundations
and/or structural steel supports.
SIGNS LOCATED IN HISTORIC DISTRICTS OR OVERLAY DISTRICTS
Historic District Approval is required by the Historic District Advisory Committee if the business is located
within a historic district. For additional information Historic is located within the Planning Department on the 2
nd
floor or Historic at (631) 451-6455.
Planning Department Approval is required if the business is located within a overlay district.
For additional information Planning is located on the 2
nd
Floor or call Planning at (631) 451- 6400.
1-2018
___
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
}
:
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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
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
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Town of Brookhaven Long Island SIGN PERMIT CHECKLIST (Town of Brookhaven)

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Completed 2 August 2020

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