application i
Office Use Only
. ' . Permit#: 56 LA ?, a28G`)-o l 9
Fee:$ 7
742 Bay Road,Queensbury,NY 12804 Invoice#: tql 7
P:518-761-8256 www.queensbury.net
SOLAR PANEL PERMIT APPLICATION D
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MAY 032 9
• Property Owner(s):
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COIName(s): 0 Aim)lic Cri-OIVA Ci
Mailing Address, C/S/Z: (92. Word-Lwool brae, Late 6-e0r (C\ ►ai i2 '4S
Cell Phone:_( ) Land Line:_( ) c - L4kAt 4- 6(921
Email: d clumu)44► 0 �►yc_ ap 0 -r, t.om
Project Address: (42 Mori-I.wt t)J( 11r`,Je
Section Block Lot: 'L cc a 1 u.- i— 3(3
Existing Use: 7.4 Single Family ❑ 2-4 Family ❑ Commercial 0 Other:
• Solar Contractor:
Workers' Comp documentation must be submitted with this application
Business Name: Piemars'e e-(eG.-r1L-G) P.,A aeex cniar Power
Contact Name: £. 4-ime.ir1J.
Mailing Address, C/S/Z: 64 raid SLreel-\Q a4,-eeAA 5/lul ‘ i 7.5&if
Cell Phone: _( ) Land Line:_( ) S'6 —14A--23g E 4 2- 2
Email: chimeaflrlrK@arA Solar fa er. iQm
• Electrical Contractor:
Workers' Comp documentation must be submitted with this application
Business Name: S,�A� co, ,-Sti 0,.,f,e
Contact Name:
Mailing Address, C/S/Z:
Cell Phone:_( ) Land Line: ( )
Email:
Contact Person for Building & Code Compliance: (A ll fkirvtdrick
Cell Phone: ( ) Land Line: ( ) Syx- 341-Z1 ri1 e A la,
Email: 2_ki mef r z➢2 6)ekp e't S oIcv power, , 11,1
Solar Panel Application Revised March 2019
Estimated cost of construction: $ 331075 '
Are the solar panels? IQ Purchased ❑ Leased
Total System Capacity Rating (sum of all panels):
Solar PV System: q kW DC
Select System Configuration:
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❑ Supply side connection with micro inverters elec )c
❑ 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.
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Homeowner's Signature Date
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Solar Co. Representative Signature Date
Solar Panel Application Revised March 2019
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apexTM
AUTHORIZATION
FORM
"TO ACT AS AGENT FOR"
I, 217 (�GiPti wn r of the premises located
at: tpo� kierigidaS iye Town of 6/Win 5 bu
Tax Parcel# c2 ge.163 -f-38
hereby designate: Apex Solar Power
as my AGENT regarding my Permit Application
for: installation of residential PV system
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Date Signature
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