application /F L a
E ( E LI V 15 Office Use Only
0 3 2019 Permit#:
APR
Fee:$ 1-5 "
742 Bay Road,Queensbury, NY 12 04T0UILDING&CODESOF Invoice#: �wlQS
P:518-761-8256 www.queensbury.net
SOLAR PANEL PERMIT APPLICATION
• Property Owner(s):
Name(s): Amber Keicher
Mailing Address, C/S/Z: 887 Ridge Road, Queensbury, NY 12804
Cell Phone: (845-443)6981 Land Line: (845 )443-6981
Email:akeicher@nyssf.com
Project Address: 887 Ridge Road, Queensbury, NY 12804
Section Block Lot: 290.14-1-32
Existing Use: 0 Single Family Et 2-4 Family 0 Commercial ❑ Other:
• Solar Contractor:
Workers' Comp documentation must be submitted with this application
Business Name: NYS Solar Farm, Inc.
Contact Name: Anthony S. Sicari, Jr. NYS Solar Farm, Inc.
Mailing Address, C/S/Z: 1938 Route 44-55, Modena, NY 12548
Cell Phone: ( ) 845-256-6041 Land Line: ( )845-256-0610
Email: bianca@nyssf.com
• Electrical Contractor:
Workers' Comp documentation must be submitted with this application
Business Name: NYS Solar Farm, Inc.
Contact Name: Anthony S. Sicari, Jr. NYS Solar Farm, Inc.
Mailing Address, C/S/Z: 1938 Route 44-55, Modena, NY 12548
Cell Phone: _( )845-256-0610 Land Line: _( )845-256-0610
Email: bianca@nyssf.com
Contact Person for Building & Code Compliance:Anthony S. Sicari, Jr. NYS Solar Farm, Inc.
Cell Phone: ( )845-256-0610 Land Line: ( )845-256-0610
Email:bianca@nyssf.com
Solar Panel Application Revised February 2019
j AMw
Estimated cost of construction: $ 14,400
Total System Capacity Rating (sum of all panels):
Solar PV System: IQ'0% kW DC
Select System Configuration:
6 Supply side connection with micro inverters
❑ 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.
see attached consent form
Homeowner's Signa Date
014/0404)
Anthony S.Sicari,Jr. NYS Solar Farm,Inc.
Solar Co. Representative Signature Date
Solar Panel Application Revised February 2019
SSUNP \'V E by e York 3 color Form
NEW YORK STATE SOLAR FARM
1938 STATE ROUTE 44/55
MODENA,NY 12548
UNIVERSAL NEW YORK PROPERTY OWNER'S ENDORSEMENT
(Person applying for building permit is not the property owner)
State of New York county of Warren --I hereby certify that
I, Amber D. Keicher am the owner in fee of
887 Ridge Rd, Queensbury, NY 12804 (address) in the Town of
Queensbury . I also hereby authorize Anthony S. Sicari, Jr. of SunPower by
New York State Solar Farm, Inc.to apply for a permit to perform the installation of a photovoltaic system
on my residence.
Owner Signature Date Oq /OZ / 1 61
SunPower®by New York State Solar Farm
SunPower®Master Dealer
Solar System Design and Installation
1938 Rt.44/55, Modena, NY 12548 Tel: 845-255-0610 Email: info@nyssf.com