Fillable Vacant-Building-Registration-Application-PDF - Vacant Building Registration Application 7.15

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Vacant-Building-Registration-Application-PDF - Vacant Building Registration Application 7.15

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U.S.A. forms for Town of Brookhaven

BROWSE TOWN OF BROOKHAVEN (NY) FORMS

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Vacant Building Registration
Donna Lent, Town Clerk rev. 7/15
One Independence Hill, Farmingville, NY 11738
(631) 451-9101 FAX: 451-9264
Chapter 87 of the Code of the Town of Brookhaven requires any owner of any building which has been
vacant for more than 120 consecutive days shall file with the Town Clerk a Vacant Building Registration.
The owner(s) of the vacant property(ies) shall be responsible to register and pay the annual nonrefundable
registration fee of $250.00. In no instance shall the registration of a vacant building and the payment of
registration fees be construed to exonerate the owner, agent or responsible party from responsibility for
compliance with any other building code or housing code requirement.
REGISTRATION REQUIREMENTS
Complete and Notarized Application _____________
Please note Application MUST include Suffolk County Tax Map No.
Valid Identification of Applicant:
Corporate Documentation _____________
Letters Testamentary _____________
Trust Document _____________
Individual Identification _____________
Registration Fee Made Payable to: _____________
“Donna Lent, Brookhaven Town Clerk”
Vacant Building Registration
Donna Lent, Town Clerk rev. 7/15
One Independence Hill, Farmingville, NY 11738
(631) 451-9101 FAX: 451-9264
VACANT BUILDING REGISTRATION APPLICATION
STREET ADDRESS OF PROPERTY BEING REGISTERED (AS LISTED ON DEED):
Property Address: SCTM #:
_______________________________
_______________________________
_______________________________
(Section) (Block) (Lot)
_______________________________
Ambulance District:
Fire District: Police Precinct:
Is this a new or renewal registration? ______ New Registration ______ Renewal Registration
Property Address: SCTM #:
_______________________________
_______________________________
_______________________________
(Section) (Block) (Lot)
_______________________________
Ambulance District:
Fire District: Police Precinct:
Is this a new or renewal registration? ______ New Registration ______ Renewal Registration
Property Address: SCTM #:
_______________________________
_______________________________
_______________________________
(Section) (Block) (Lot)
_______________________________
Ambulance District:
Fire District: Police Precinct:
Is this a new or renewal registration? ______ New Registration ______ Renewal Registration
Office Use Only
Check #: Process Date: Receipt #:
Vacant Building Registration
Donna Lent, Town Clerk rev. 7/15
One Independence Hill, Farmingville, NY 11738
(631) 451-9101 FAX: 451-9264
1. If the owner is a corporation or LLC, provide the names, residence addresses, telephone numbers and email
addresses of all officers, directors and managing member as well as a copy of the most recent annual franchise tax
report filed with the Secretary of State.
a. _________________________________________________________________________
b. _________________________________________________________________________
c. _________________________________________________________________________
d. _________________________________________________________________________
2. If an estate, the name, business address, telephone number and email address of the executor of the estate.
a. _________________________________________________________________________
3. If a trust, the names, addresses, telephone numbers and email addresses of all trustees and grantors.
a. _________________________________________________________________________
b. _________________________________________________________________________
4. If a partnership, the names, residence addresses, telephone numbers and email addresses of all partners with an
interest of 10% or greater.
a. _________________________________________________________________________
b. _________________________________________________________________________
c. _________________________________________________________________________
d. _________________________________________________________________________
5. If any other form of unincorporated association (ie. D/B/A), the names, residence addresses, telephone numbers
and email addresses of all principals with an interest of 10% or greater.
a. _________________________________________________________________________
b. _________________________________________________________________________
c. _________________________________________________________________________
d. _________________________________________________________________________
6. If an individual person, the name, residence address, telephone number and email address of that individual
person.
a. _________________________________________________________________________
_________________________________________________________________________
Please note: If the owner or owners do not reside within the State, the registration statement must also provide
the contact information for a local agent who resides within the State and who is authorized to accept service of
p
rocess on behalf of the owners. (Attach Additional Sheets If Necessar
y
)
Vacant Building Registration
Donna Lent, Town Clerk rev. 7/15
One Independence Hill, Farmingville, NY 11738
(631) 451-9101 FAX: 451-9264
7. Contact Person in the event of an emergency affecting the public health, safety or welfare.
Please Note This Person MUST Be Located Within New York State.
Name: _______________________________ Phone #: _____________________________
Mailing Address: ______________________________ Email: _____________________________
Maili______________________________
I do hereby certify that all statements made by me in this vacant building registration are true and correct
to the best of my knowledge, information and belief, further, I understand that in the event that I have
knowingly and willfully made any false statements, I will be liable for punishment in accordance with all
applicable laws and statutes.
SIGNATURE _______________________________
APPLICANT’S NAME _______________________________
TITLE _______________________________
Acknowledgment of Individual
STATE OF )
COUNTY OF ) SS.:
On the ____________ day of _________________ in the year 20___ 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
Acknowledgement of Corporation
STATE OF )
COUNTY OF ) SS.:
On the ____________ day of _________________ in the year 20___ before me personally came
_____________________________ to me known, who, being by me duly sworn, did depose and say that
he/she/they reside(s) in ___________________________________________ (if the place of residence is in a city,
include the street and street number, if any, thereof); that he/she/they is (are) the __________________________
(president or other officer or director or attorney in fact duly appointed) of the (name of corporation), the
corporation described in and which executed the above instrument; and that he/she/they signed his/her/their name(s)
thereto by authority of the board of directors of said corporation.
______________________________
Notary Public
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Completed 11 July 2020

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