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
5-11-16 DEBRIS AFFIDAVIT
Permit # ____________________
STATE OF NEW YORK)
COUNTY OF SUFFOLK)
I, ______________________________________, being duly sworn, depose and say that I am the applicant for
a Certificate of Occupancy on the premises known as number _____ on the N S E W side of
_____________________________, a distance of ________’ N S E W of ________________________, in the
hamlet of ______________________, Tax Map # __ __ __ __-__ __ __.__ __-__ __.__ __-__ __ __.__ __ __,
State of New York, and that I am familiar with the terms and conditions of the Tree and Debris Disposition
Law of the Code of the Town of Brookhaven, that neither I nor any of my agents, servants or employees have
knowingly buried or permitted to be buried, trees or debris in, upon or under the parcel for which the
Certificate of Occupancy is sought, nor has any debris been abandoned on said property and that all debris has
been removed and disposed of in a lawful manner; nor do I have knowledge that any other person, individual,
firm, partnership, association, corporation, company, public utility or organization of any kind, or agent
thereof, have buried trees or debris in, upon, or under the parcel for which the Certificate of Occupancy is
sought; nor will the undersigned or its agents, servants and employees knowingly permit tree or debris to be
buried upon the parcel for which the Certificate of Occupancy is sought. This affidavit is made pursuant to the
requirements of Section 16-4-B of the Code of the Town of Brookhaven and is necessary prerequisite for the
issuance of a Certificate of Occupancy.
I hereby certify under penalty of perjury that I am acting on my own behalf and that the foregoing statements are
true and correct to the best of my knowledge and belief.
(Signature of Affiant)
Personally appeared before me the above named personally known to me,
who being duly sworn, deposes and says that he/she executed the above instrument and that the statement and
answers contained therein are true and correct to the best of his/her knowledge and belief.
Subscribed and sworn to before me this day of ,20________.
__________________________________
Notary Public
