Renew Your Rental License

INSTRUCTIONS

The following House Rental Registration may be available for renewal online:
• Original agent/expediter continues to represent owner of property or the Owner now represents themselves. Please note that if a new agent/expediter is used this renewal cannot be processed online.
• Number of maximum occupancy and number of bedrooms has not changed.
• Single Family Rental Only. Duplex and Multi-Family rentals are NOT eligible for online renewals.
• Ownership has not changed.
• No Town Violations
• A sworn affidavit must be received by and approved by the Building Department prior to the issuance of the Provisional House Rental License.

NOTE: This application is for temporary registration only and does not constitute an effective Provisional House Rental License.

*** All residents renewing a Town of Brookhaven Building Department permit using a credit card or debit card will
be charged a 2.35% convenience fee, or a $1.50 convenience fee if 2.35% of the renewal cost is below $1.50. ***

HOUSE RENTAL REGISTRATION LOOKUP

Suffolk County Tax Map Number:*
You can find your tax map number on your Tax Bill. Click here for example.

HID Physical Address JS:

Physical Address:
21 NORTH HAMPTON AVE, MILLER PLACE

Eligible Registrations:*

Ineligible Registrations:

OWNER INFORMATION

Work Description:

I am the *

Owner
Agent acting for the Owner

Property Owner First Name:*

Property Owner Last Name:*

Property Owner Phone Number:*
###-###-####

Property Owner E-mail Address:*

Property Owner Mailing Address:*

Property Owner Zip Code:*

Physical Address:
21 NORTH HAMPTON AVE, MILLER PLACE

CERTIFICATION OF STRUCTURES

Other than the allowable work covered by the single house rental registration needing renewal, I hereby attest that no additional structures or improvements have been made to the property since the submission of the original Certification of Structures form. *

YesNo

I further attest that all statements made herein are true and correct to the best of my knowledge, information and belief. I further 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. *

YesNo

BUILDING APPLICATION

I hereby affirm that no work will be done prior to the issuance of the above house rental registration and all continued work will be in conformance with the scope of the permit, survey, and plans submitted pursuant to Section 57 of the Worker’s Compensation Law, the Brookhaven Town Code, any and all applicable local, city, state and federal zoning ordinances, building codes, fire safety codes, health codes and property maintenance codes. Article 15 of the Executive Law of the State of New York, Section 296-5 (A)(1) prohibits discrimination in the sale, rental or lease of housing accommodations because of race, creed, color, or national origin. *

YesNo

I hereby agree and intend to sign and affirm by clicking this box I have read and understand the terms and conditions of this application. *

YesNo

I understand that my signing and submitting this application in this fashion is the legal equivalent of having placed my handwritten signature on the submitted application and this affirmation. *

YesNo

I understand and agree that by submitting this application in this fashion, I am affirming to the truth of the information contained herein and that I am the property owner for the house rental registration being renewed. *

YesNo

I understand and agree that the Building Division reserves the right to review the details of this renewal application including but not limited to: fee calculations, review of the scope of proposed work, or violations research and may contact me to verify and correct such information prior to the issuance of the renewed House Rental Registration. *

YesNo

I affirm that there are no existing or outstanding violations of any Federal, State, or County Laws or Rules or Regulations or of any Town of Brookhaven Local Laws or Ordinances pertaining to this property; and that there are no changes to any information as provided on the prior valid Rental Registration and Application. *

YesNo

I/My Client have not altered the floor plan or use of all rooms or areas of residence since the issuance of the previous rental registration. *

YesNo

I acknowledge that I am aware of the definition of Family in 85-1 of the Brookhaven Town Code which allows for a residence to be rented to no more than 3 Persons not considered a family. I further understand that the Temporary Rental Registration and Provisional House Rental License description may be altered to reflect compliance with the Code. *

YesNo

ETHICS DISCLOSURE

Does any officer or employee of the Town of Brookhaven, member of an executive committee of a political party, or his/her spouse, brother, sister, parent, child, grandchild, or spouse of any of them, have an interest in this application by virtue of being the actual applicant, being the owner of the actual property or having an interest in the corporation, partnership or association making such application? *

YesNo

This form is for:*
An Individual
A Corporation
A Partnership
An Association

FOR INDIVIDUAL
Interested Party Name:

Interested Party Address:

FOR CORPORATION
Interested Party Name:

Interested Party Address:

Title:

Department:

Relationship to Public Officer / Employee and Title if Other Than Self:

Is the owner of greater than five percent (5%) of the corporate stock of the application when the applicant is a corporation whose stock is publicly traded.:
YesNo

The actual applicant, :
YesNo

An Officer, Director, Partner, or Employee of the applicant, or :
YesNo

Legally or beneficially owns or controls any stock of a non-publicly traded corporate applicant or is a member of a partnership or association of the applicant. :
YesNo

FOR PARTNERSHIP OR ASSOCIATION:
Interested Party Name:

Interested Party Address:

Title:

Department:

Relationship to Public Officer / Employee and Title if Other Than Self:

Does the owner hold greater than five percent (5%) interest of publicly traded shares?:
YesNo

The actual applicant, :
YesNo

An Officer, Director, Partner, or Employee of the applicant, or :
YesNo

Legally or beneficially owns or controls any stock of a non-publicly traded corporate applicant or is a member of a partnership or association of the applicant. :
YesNo

PAYMENT INFORMATION

Renewal Fee:

Discount Amount:

Discounted Fee:

Credit Card Convenience Fee:

Total Cost:

Payment Breakdown
Rental License Renewal Fee:

Rental License Online Discounted Fee (House Rentals Only):

Credit Card Convenience Fee:
Total Cost:

Street Address:*

Billing Address Zip Code:*

Credit Card:*

Name on Credit Card:*

Credit Card Number:*

Credit Card CVV2 Verification Code:*

Credit Card Expiration:*

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Serv_Prov_Code:

B1_Per_ID1:

B1_Per_ID2:

B1_Per_ID3:

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