Division of Building
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
Town of Brookhaven
Long Island
VOID PERMIT REQUIREMENTS--STRUCTURES
If you were issued a permit and did not build the structure(s) do the following:
1. Fill out Void Permit Request for Structures and notarize.
2. Submit a copy of the permit(s) (if available).
3. Submit a copy of the survey or site plan showing the location of the
proposed construction.
4. Complete, sign and submit “Certification of Structures” form.
5. Photographs of ALL sides of ALL structures.
If the structure(s) were built and have since been removed, you may not request a
Void Permit. You must apply for a permit for existing demolition of the
structure(s).
The permit will be voided after the Inspector performs an inspection and approves
the Void request. A letter will be mailed to the applicant stating the permit has
been voided.
1-2018
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