**ALL APPLICATIONS MUST BE COMPLETE AND LEGIBLE FOR ACCEPTANCE
INCLUDING ALL REQUIRED TO SCALE DRAWING, PHOTOS, AND OTHER SUPPORTING DOCUMENTS.**

Today’s Date: _______________

Address of Proposed Work:
_______________________________________________________

*****

Owner Name: ____________________________________________
Address: ________________________________________________
_______________________________________________________
Day Phone ________________ Evening Phone __________________

*****

Applicant Name: __________________________________________
Address: ________________________________________________
_______________________________________________________
Day Phone ________________ Evening Phone __________________

*****

Agent/Contractor: ____________________________________________________________
Agent/Contractor Address: _____________________________________________________
Agent/Contractor Phone: _________________________ Fax: __________________________

TYPE OF STRUCTURE:
____ Residential _____ Commercial _____ Garage/Outbuildings _____ Fence _____ Sign

TYPE OF WORK PROPOSED:
____ Restoration ____New Construction ____ Addition/Alteration ___Repair ____ Demolition/Removal
____ Lighting ___ Awnings _____ Signs _____ Fence _____ Window/Door Replacement _____ Siding

AREA TO BE AFFECTED:
____Siding _____Windows ____ Doors ____ Chimney ____ Porch/Railings ____ Sign ___________ Other

SUPPORTING DOCUMENTATION:
_____ Project Description ____Photos ____ Drawings ____ Size/Style _____ Materials list ____ Colors Used
_____ Tape location map ____ Instrument survey map _____ Year of original construction _____Year of addition

VILLAGE OFFICE USE:
_____ Plan conforms to zoning _____ Pre-existing Nonconforming Use _____Variance required ____Variance granted
_____ SEQR required _____ National Register District

Building Inspector signature: _________________________________ Date: __________________________

PLEASE DESCRIBE PROJECT IN DETAIL:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________

*** PLEASE NOTE THE FOLLOWING***

1. This application can not be processed for APRB review unless all of the required items set forth on the requirements
   form are submitted to the Village Office by the deadline date (see attached schedule).
   
2. All zoning requirements, including variances, must be met prior to APRB approval.
   
3. All required State Environmental Quality Review Act (SEQR) forms must be attached.
   
4. Decisions are based on the Secretary of the Interior Standards for Historic Rehabilitation and the Village of Pittsford
   Code Article XIV, Section 210-57 – 210-65.
   
5. The applicant or his agent must appear at the scheduled meeting when the completed application will be reviewed by
   the APRB. An agenda with an approximate time for review will be sent to all parties prior to the meeting. A letter
   stating the APRB decision will follow the meeting.
   
6. Work on projects shall not be started unless the applicant has received APRB approval and all the necessary permits
   have been obtained from the Building Inspector. To obtain the necessary permits, please contact the Building Inspector
   at 586-4332.
   
7. Changes to the approved plan can not be made without additional APRB review. A written request for a change in application including the revised proposed plans must be received by the deadline date.
   
8. Approvals are valid for one (1) year from the date of APRB approval.

Owner Signature: ________________________________________ Date: __________________________
Applicant Signature: ______________________________________ Date: __________________________
Agent/Contractor Signature: ________________________________ Date: __________________________
**************************************************************************************************

FOR ARCHITECTURAL & PRESERVATION REVIEW BOARD USE:

Decisions are noted by date reviewed:

Approved: ____________________________
Approved with Conditions: ______________________
Left Open: ____________________
Tabled: _______________________
Denied: ________________

Chairperson’s Signature: ____________________________________ Certificate No. ________