Town of Brookhaven
Long Island
VOID PERMIT REQUEST—SOLAR
Please send completed form to Town of Brookhaven, Building Division, One Independence Hill,
Farmingville, N.Y. 11738.
Suffolk County Tax Map Number: - ----------------------------------
Building/House Number: N S E W side of:
Distance: , N S E W of
Hamlet: , State of New York
Permit #:
Owner’s Name: Owner’s Email:
Owner’s Mailing Address:
Owner’s Phone:
(H) (W) (C)
I respectfully request that the above referenced Building Permit be voided and hereby certify that the
scope of work of the subject permit has not been constructed.
Owner’s Signature Date
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
Commission Number
Signature
Expiration Date
Division of Building 7-2018
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
