Town of Brookhaven: Application for a Wetlands and Waterways Permit
and/or
Coastal Erosion Management Permit
________________________________________ _________________________
name of applicant phone/fax
___________________________________________________________________________________________________________
mailing address/PO Box Hamlet State Zip Code
________________________________________ _________________________
name of property owner (if different from above) phone/fax
___________________________________________________________________________________________________________
mailing address/PO Box Hamlet State Zip Code
________________________________________ _________________________
name of agent (if any) phone/fax
___________________________________________________________________________________________________________
mailing address/PO Box Hamlet State Zip Code
Project Location: N S E W side of _____________________________________________, #__________
name of street house number
___________ feet N S E W of ____________________________________, ________________________
distance in feet nearest cross street Hamlet
S.C. Tax #: __________ __________ __________ __________ Item # ________________________
District Section Block Lot per tax bill
Applicant Requests: Wetlands Permit Coastal Erosion Management Permit Combined Permit
Wetlands Delineation Only
Project Description:
Bulkhead Dock Residence Accessory Structure Addition to Existing Structure
(check all that apply)
Other________________________ New Existing
Dimensions: ___________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
This project will require the following Town of Brookhaven approvals:
Building Permit
HDA Zoning Board Approval Site Plan Approval Subdivision Approval (Planning Board)
This permit will require additional permits from the following agencies:
S.C. Dept. of Health Services N.Y. State D.E.C. Army Corps of Engrs.
Certification:
The applicant/owner of the property certifies that the above statements are true and agrees that the issuance of the permit is based on the
accuracy thereof. As a condition of the issuance of a permit, the applicant accepts full legal responsibility for all damage direct or
indirect, of whatever nature, and by whomever suffered, arising out of the project described herein and agrees to indemnify and save
harmless the Town from suits, actions, damages and costs of every name and description resulting from said project.
__________________________________________________________ ___________________________________________________________
Signature of Applicant/Agent Signature of Owner (if not the same)
Dated: _____________________
_____ Received check $ ___________ Application Number _______-____________-_______
SEQR Type _____________ Analyst ___________ Category____________
For additional information, contact:
Town of Brookhaven, Division of Environmental Protection, One Independence Hill, Farmingville, NY 11738 (631) 451-6455
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