Town of Brookhaven
STRUCTURE VOID PERMIT REQUEST
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: ______________________ Owners Email: _____________________
Owners Mailing Address: __________________________________________________
Owners 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 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_________________________ Signature________________________
Commission Number _________________ Expiration Date ___________________
03/2016
