Fillable Town of Brookhaven Long Island SOLAR PANEL PERMIT (Town of Brookhaven)

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Town of Brookhaven Long Island SOLAR PANEL PERMIT (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
1-2020
SOLAR PANEL PERMIT REQUIREMENTS FOR
ONE- AND TWO-FAMILY DWELLINGS
PLEASE SUBMIT THE FOLLOWING VIA EMAIL IN TWO SEPARATE PDF FILES TO
buildingplans@brookhavenny.gov:
1 – THE PERMIT APPLICATION FILE MUST BE IN PDF FORMAT TO INCLUDE THE FOLLOWING
DOCUMENTS:
• APPLICATION SUBMISSION FORM – completed and signed
• BUILDING PERMIT APPLICATION – Town of Brookhaven application completed and signed (make sure
that you have the correct mailing address for the applicant, owner, and engineer/architect). The application must
include the total panel count and the total kilowatt rating. If roof reinforcement is required, it must be stated on
the application along with the cost of the reinforcement work.
• TRANSACTIONAL DISCLOSURE – completed and signed
• WORKERS COMPENSATION AND DISABILITY – 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.
• HDAC- Town of Brookhaven Historic District Advisory Committee approval when necessary.
2 – THE PLANS FILE IN PDF FORMAT MUST INCLUDE THE FOLLOWING:
• PLANS - Plans are required to:
- List location of installation including street address, Suffolk County Tax Map # and property owner’s name.
- Sealed and signed by a NYS Professional Engineer (PE) or NYS Registered Architect (RA).
- State design professional’s address, phone number, and e-mail address shall be included on plans.
- State solar panel load and total load on roof. Indicate number of roof shingle layers.
- Show layout of solar panels including roof access, pathways, and spacing.
- Indicate mounting hardware and height above roof surface. (maximum of 6”)
- Statement that the design complies with the 140 m.p.h. wind requirement (http://windspeed.atcouncil.org),
2015 IRC, 2016 NYS Supplement (R 324), NEC 2014 and ASCE7-10
The Permit fee of $107.06 is to be submitted by cash, check, credit card or Trust Account. This fee will be payable
at the time of permit issuance.
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
PERMIT APPLICATION SUBMISSION FORM
APPLICANT’S NAME:
(Owner of Property)
ADDRESS OF PROPERTY:
HAMLET:
TAX MAP NUMBER:
PLEASE NOTE: Plans will not be accepted if any of the above information is not
complete.
For Building Department Use Only:
ITEM NUMBER:
PERMIT NUMBER:
PERMIT STATUS:
EXPIRATION DATE:
www.brookhavenny.gov
1/24/17
___
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
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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:
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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 SOLAR PANEL PERMIT (Town of Brookhaven)

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Completed 2 August 2020

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