Owner
Agent for Owner

Other than the allowable work covered by the single permit 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. 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.*
Yes
No

I hereby affirm that no work will be done prior to the issuance of the above permit 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. 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. 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. 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 permit being renewed. 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 permit.*
Yes
No

It is correct that no 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.*
Yes
No

• Credit Card Convenience Fee: 2.35% of purchase with a minimum of $1.50
• e-Check Convenience Fee: $0.75

Credit Card
e-Check