application 1=1._
771.\ Office Use Only
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Permit#: 5
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II AUG 1 2 2019 Fee:$ Of,
742 Bay Road,Queensbury,NY i2804/ TOWN OF OUEENSBURY invoice# bccb-S
Pi 518-761-8256 www.queensbury.n'et. BUILDING&CODES i
SOLAR PANEL PERMIT APPLICATION
• Property Owner(s):
Name(s): st110,1-1
Mailing Address, usg: ran IL. Delve\&viefanS N‘i Vi-S"Oti
Cell Phone: ) glcs- (0‘17-33 i Land Line: )
Email: arnv Saliv6-1-1 C1.0 crcurp:etim
Project Address: 3i granI4 t)ii‘re_ • - •
: • •
Section Block Lot: - q-- 1— iL.9
Existing Use l Single Family 0 2-4 Family a-Comrriercial 0 Other:
• Solar Contractor:
Workers' Comp documentation must be submitted with this application
Business Name: rice• EA 5^104-. Payer
Contact Name: Caeb../
tJrfrJ-
Mailing Address, C/S/Z :fa tA mum <4-re_e-/-‘ u‘e.enckur9,,r44. -
Cell Phone _( ) . Land Line ( ) (2121
Email: ().0tiv I rid(
• Electrical Contractor dme csSe,far cop:I-radar-
Workers':Camp documentation must-be submitted with this application •
BuSiness Name: -
!Contact Name: . . _ . _ .
Mailing Address, C/S/Z:
Cell Phone: (. ) Land Line: ( ) s
Email: - . . . •
Contact Person for Building & Code Compliance: C,odLi 14-irke_Irter- . •
Cell Phone: ( ) Land Line: ( ) cte6- log fs-4 (2,12.1
Email: - usAcIrie ckre_).( gniqr
Solar Panel Application Revised March 2019 -
Estimated cost of construction: $ .1 ccs 636 Jac)
Are the solar panels? [ I Purchased ❑ Leased
Total System.Capacity Rating (sum of all panels):
Solar PV System: (0.0 kW DC
Select System Configuration: .<fse,cse see ;ncJu4ed f fan se cord
D. Supply side connection with micro inverters €f ecArk AJ aIct,etre
❑ Supply side connection with DC optimizers
❑ Supply side connection with string inverter
❑ Load side connection with DC optimizers
❑ Load side connection with micro inverters
❑ Load side connection with string inverter
Please sign below to affirm that all answers are correct and that you have met all the
conditions and requirements to submit a unified solar permit
P f ea fe. See a14-ete..keei f rn y 1 e4-t
Homeowner's Signature � Date
aPit,A; La / q X Star f at re
Solar Co. Representative Signature Date
Solar Panel Application Revised March 2019
•
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AUTHORIZATION
FORM
"TO ACT AS AGENT FOR"
Salvatl . • .. ..
I Amy owner of the premises located . .
.-31 Bronk' Drive Queensbu
at. . .. . .. .. :.. ' : : Town.of.. rY
Tax.Parcel#
hereby designate: . Apex.Solar..Power. -
as my AGENT regarding my Permit Application
for: • _.•installation of residential PV system
Jul 25 2019 n_ -
C4fLj-' MIMI/
Date . .Signature