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11060180 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10620 CULBERTSON DR CONTRACTOR:3D DATACOM PERMIT NO: 11060180 OWNER'S NAME: WRIGHT MARK B E AND MAN-WAI 11365 SUNRISE GOLD CIR DATE ISSUED:06/21/2011 (IWNER'S PHONE: 4082030942 RANCHO CORDOVA, CA 95742 PHONE NO:(925)455-1884 u LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG� ELECT r- PLUMB License Class Lic.# 7/-5 ! MECH[_ f—RESIDENTIAL COMMERCIAL Contractor - y lJC ��c �i �i Date (e2 ,;z /I JOB DESCRIPTION: INSTALL ELECTRICAL CAR CHARGER 1 hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000)of Division 3 of the Business&Professions Code and that my license is in full force and effect. hereby affirm under penalty of perjury one of the following two declarations: I have and will maintain a certificate of consent to self-insure for Worker's Compensation,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$842 1 have and will maintain Worker's Compensation Insurance,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this APN Number:37534031.00 Occupancy Type: permit is issued. 'D–b APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED correct. I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save 180 DAY FROM LAST CALLED INS N. indemnify and keep harmless the City of Cupertino against liabilities,judgments,costs,and expenses which may accrue against said City in consequence of the Issued by: ZZ� Date: granting of this permit. Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. (� RE-ROOFS: Signature 4416,_Date vZ r / All roofs shall be inspected prior to any roofing material being installed.If a roof is installed without first obtaining an inspection,1 agree to remove all new materials for inspection. OWNER-BUILDER DECLARATION Signature of Applicant: Date: 1 hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER I,as owner of the property,or my employees with wages as their sole compensation, will do the work,and the structure is not intended or offered for sale(Sec.7044, Business&Professions Code) I.as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the California Health&Safety Code,Sections 25505,25533,and 25534. 1 will 1 hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the declarations: Health&Safety Code,Section 25532(a)should I store or handle hazardous I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District I performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,S s 25505,2553 ,and 25534. Section 3700 of the Labor Code,for the performance of the work for which this (r'/t Owner or authorized age t: � t�' Date: permit is issued. I certify that in the performance of the work for which this permit is issued,I shall not employ any person in any manner so as to become subject to the Worker's CONSTRUCTION LENDING AGENCY Compensation laws of California. If,after making this certificate of exemption,I become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby affirm that there is a construction lending agency for the performance of forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued(Sec.3097,Civ C.) Lender's Name APPLICANT CERTIFICATION Lender's Address I certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION indemnity and keep harmless the City of Cupertino against liabilities,judgments, s,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records. .Ming of this permit.Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional 9.18. Signature Date ChargeP# int by Coulomb Technologies f ,y clr, m .. µ sr . _ ..._ _✓ _ ' -. _k : `tet ' " � ea CT500 ChargePoint®Networked Charging Stations, by Coulomb Technologies,offer municipalities,corporations,fleets, and utilities, high reliability,plug-in electric vehicle charging that drivers prefer.The easy-to-use stations provide multiple power options, integrating aesthetics and ergonomics with sturdy construction—ideal for residential, commercial and outdoor public applications. The CT500 charging station is a 7.2 kW single output station designed for single and multi-family homes,apartments and condominium buildings,light commercial and fleet applications for the North American marketplace.The station delivers Level II(208/240 V 30 A)charging and is compatible with plug-in electric vehicles that comply with the SAE J17721 plug-in electric vehicle charging standard. The station's small size r and flexible interfaces for utility Automatic Meter Infrastructure(AMI)make it an ideal f 4. solution for homeowners,utilities, fleet managers, and property managers. To eliminate energy theft and to enhance safety,a card reader option is available for drivers to access and energize the station with a ChargePass''card.The station's highly visible display guides drivers with instructive messages and can be used to display custom advertisement or greetings for drivers. Wfware Application Services Set pricing and collect fees,provide 24/7 driver assistance,control access,display advertisements, track usage, and diagnose the station rem tely using the growing suite of ChargePoint Network on-demand softwaM cppww d a web browser. .40 Pro ' nal driver n Gusto ontrol,preventing electricity theft Ind enha ety,with ed standards00 reader that accepts ePass car U°\8\N0 0 IC � due 40$VM'o YOwed 0W'ms ®o eA Ert;ur(p,,W,eggs d�jK l n�wk�p��r if auth_or1z he EV cord is properly serted;`` �3k3ogeo%-! a�5 p�'�` d6}not1�+M'W�+ �J e€wr ws<: u f� :,, su i.zin c aoz ��l l+, o� n°ad 01 se q°� ,Vacuum , >n <g ;: 1 �. H� m9 e'�� o suo!�� °6�1�rp els Display instructive, advertisement, and greeting messages in m4qt\li}(tg �s'q�nai�Dk# 1ea�yp(� � �d s s =;i W €,f s.of"> .rct c,rl �,<•�•�o�\�}Me1u ods 8vo!'kso\�! o;°>�ti•� n\N • Ground Fault Detection: Integrated hardware ground-fault Aie i4.21t&R bith i +dffver r�i tion • Over-Current Detection: Disconnects power to prevent nuisV&breaker trips at s c pan 440)gRotification. • Plug-Out Detection:Algorithm disengages power and notifies the driver when a 61 3 ,Rao 1 VAIV4 'r Keep charging station current with future and evolving EV needs by upgrading station firmware remotely over-the-air. Provide accurate bi-directional energy measurement with integrated power metering circuitry. Coulomb Minimize the need for on-site maintenance with real-time remote alarm monitoring and control. �M Technologies I.-, Nc,t,-CA-k iia era,"''.3Coulomb Technologies,Inc. 1692 Dell Ave. Wireless mesh and cellular network interfaces allow seamless integration with the ChargePoint Campbell,CA 95008-6901 USA Network and ChargePoint Network application services. US toll free:+1-877-370-3802 www-coulambtech.com „ w Gid w : £^-w -- www.mychargepoint.net a Enable Time-Of-Use(TOU)pricing and demand response by integrating with Advanced Metering - - - - - Infrastructures(AMls). U Listed by Underwriters Laboratories Inc. C US LISTED .,..•. �...:,-.'..`_..,.�.,....`.,..,,...,,.,.,,..".�....,�...,�..,..�,....,.�.....,.,.,...M.,w.....,.�,....,............�,�,..µ,.�.,.....m...._...w.............................,,.�1 w/ .._1.,... P/N:73-001001-01 Re,1 V`•L� E328 `f7 �, 4 N by Coulomb Technologies v e d n 1 p., f Drawings Y.r/'wk i V 88 S�y° ... . ............ .... 4 in 4.8 in 101.6 mm 121.4 mm 22 in 558.8 mm 17.2 in 436 mm _ 0 o in 306. 306.3 mm 22.1 in 560.3 mm 33.2 in 842.5 mm "MALL 3`o a.U N f ( T 503) 16 in 406.4 mm MOUNTING Ds E.i::�S '(�s e 0 e O 4.5 in 114 mm o00 0 o o rf� Y� o �Y (4X) .25 IN DIA LAG SCREW 6 MM DIA LAG SCREW Listed by Underwriters Laboratories Inc. C U` Us UMD i n t by Coulomb Technologies S ic,c2 c c a t i o n s CT500 Input Power 7.2 kW Input Voltage 208/240 VAC Input Current 30A Input Power Connections Line 1, Line 2, Earth . ................................ .......... Required Service Panel Breaker 40 A double pole breaker(non-GFCI type)on dedicated.circuit Standby Power 5 W typical .............. ............. .... ......... Output Charging Power 7.2 kW . ......... ....... Output Voltage 208/240 VAC Output Current 30A .......... Output Charging Connector SAE J17721 EV connector on 18' (5.48 m)cable ...................... Fumcldoina', �nterfac�, ............. Card Reader ISO 15693, 14443 ...... .. ....................... ..... Ground Fault Detection 20 mA CCID with auto retry(15 minute delay,3 tries) Plug-Out Detection Power terminated per SAE J11772'111 specification Power Measurement 2%@ 15 minute intervals Local Area Network 2.4 GHz 802.15.4 dynamic mesh network Wide Area Network Commercial CDMA or GPRS cellular data network .............. ............ at 'Safety Compliance UL Listed for USA and cUL certified for Canada;Complies with UL 2594,UL 2231 1, UL 2.231-2,UL 1998,_ UL 991,NEC Article 625 ............. Surge Protection 6 kV @ 3,000 A. In geographic areas subject to frequent thunderstorms,supplemental surge protection is recommended. EMC FCC Part 15 Class B Operating Temperature -22°F to 122°F(-30°C to+50°C) Operating Humidity 95%non-condensing Enclosure NEMA 3R Terminal Btock Temperature Rating 217 F(100°C) Maximum Charging Stations per 24. Eackstation must be within 150 feet(46 meters)"line of sight"of at least one other station. 802.15.4 Radio Group Approximate Shipping Weights 26 lbs(12 kg) Coulomb Technologies,Inc.reserves the right to atter product offerings and specifications at any time without notice,and is not responsible for typographical or graphical errors that may appear in this document. Listed by Underwriters Laboratories Inc. C @ us LISTED r p � M QL'Mrv, Pd,: .ulr E.4 „ Yws �Y`t ` IWW:'iYs,�3.'ey by Coulomb Technologies .�., r F ff t F^ : " .s, CT500 M. 2.0 s !,E r:f%:?" M Specify model number followed by the applicable code(s).The order code sequence is: If ordering this The order code would be Model-Modem-SIM-Local Area Network-Warranty Wall Mount with CDMA Gateway Modem, RFID Card CT503-CDMA-RFID-ZIG Option Order Code Reader, and LAN Model Walt Mount CT503 Wall Mount with GPRS Gateway Modem' F Modem,and USA GPRS SIM CT503-GPRS-SIM1 Integral CDMA ChargePoint CDMA Gateway Modem ....... -- Wall Mount with Card Reader, Integral GPRS ChargePoint -GPRS LAN, and 5 year extended CT503 RFID ZIG EWSRFIDZIG Gateway Modem parts warranty SIM USA GPRS SIM SIM1 Canada GPRS SIM -SIM2 Card Reader RFID Card Reader -RFID Local Area Network„(LAN)" 802.15.4 wireless mesh interface -ZIG Warranty For ricin and additional product 5 Year Parts Only Extended Warranty: P Gateway EwSGw information, contact the distributor in your 5 Year Parts only Extended Warranty: area. For a complete list of distributors, go to Gateway, LAN,and Card Reader EW5GWRFIDZIG www.coulombtech.com and click Purchase. 5 Year Parts Only Extended Warranty: EW5RFIDZIG Card Reader and LAN 'Specify at iecst one modem or LAN option(or both) Coulomb Technologies, Inc. - 1692 Dett Ave. -Campbelt, CA 95008-6901 USA 408.841.4500-877.370.3802-info@coutombtech.com www.cotllombtech.com -www.mychargepoiiit.net U` Listed by Underwriters Laboratories Inc. C US LISTED Copyright m 2010 Coulomb Technologies,Inc.All rights reserved.CHARGEPOINT is a U.S.registered trademark/service mark,and an EU registered logo mark of Coulomb Technologies,Inc.ALI other products or services mentioned are the trademarks,service marks,registered trademarks or registered service marks of their respective owners.Coulomb Technologies has several patent applications filed. CITY OF CUPERTINO 5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: SylviaM COPY # 1 Sec : Twp: Rng: Sub: Blk: Lot : APN . . . . . . . . : 37534031 . 00 DATE ISSUED. . . . . . . : 06/21/2011 RECEIPT #. . . . . . . . . : BS000013843 REFERENCE ID # . . . : 11060180 SITE ADDRESS . . . . . : 10620 CULBERTSON DR SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER WRIGHT MARK B E AND MAN-WAI ADDRESS 10620 CULBERTSON DR CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : 3D DATACOM CONTRACTOR BRIAN BOYLE LIC # 27773 COMPANY 3D DATACOM ADDRESS . . . . . . . . . . : 11365 SUNRISE GOLD CIR CITY/STATE/ZIP . . . : RANCHO CORDOVA, CA 95742 TELEPHONE (925) 455-1884 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 842 . 00 1 . 00 0 . 00 1 . 00 0 . 00 1BREMPOWER POWER UNITS 1 . 00 158 . 00 0 . 00 158 . 00 0 . 00 1BSEISMICR VALUATION 842 . 00 0 . 50 0 . 00 0 . 50 0 . 00 1EPERMITFE FLAT RATE 1 . 00 42 . 00 0 . 00 42 . 00 0 . 00 1TRAVDOC FLAT RATE 1 . 00 42 . 00 0 . 00 42 . 00 0 . 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 243 . 50 0 . 00 243 . 50 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CHECK 243 . 50 2128 --------------- TOTAL RECEIPT 243 . 50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 101 FOUNDATION 103 UFER 104 REBAR 105 ANCHOR BOLTS 304 ROUGH ELECTRICAL 501 FINAL ELECTRICAL ENERGY 505 FINAL ELECTRICAL 510 FINAL PLANNING CITY OF CUPERTINO FEE ESTIMATOR - BUILDING DIVISION [al ADDRESS: 10620 CULBERTSON DATE: 06/21/2011 REVIEWED BY: MENDEZ APN: BP#: *VALUATION: $842 °PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration /Addition / Repair PRIMARY SFD or Duplex PENTAMATION USE: pPERMIT TYPE: 1 REAP8 WORK SCOPE APPLIANCE/ EQUIP TYPE FEE ID QTY UNITS BP FEES Other Power Devices 1BREMPOWER 1 # $158 TOTALS: 1 $158.00 Elec. Plan Check 0.0 1 hrs $0.00 Elec. Permit Fee: 1EPERMIT Other Elec. Insp. 0.0 hrs $42.00 NOTE. These,fees are based on the preliminary information available and are onl an estimate. Contact the De t or addn'l info. FEE ITEMS (Fee Resolution 09-051 Elf. 7/1/10) FEE QTY/FEE MISC ITEMS PME Plan Check: $0.00 PME Unit Fee: $158.00 PME Permit Fee: $42.00 F] Work Without Permit? O Yes (D No $0.00 Travel Documentation Fee: ITRA VDOC $42.00 Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $243.50 $0.00 TOTAL FEE: $243.50 Revised: 03/01/2011 GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255LM (408)777-3228• FAX(408)777-3333•building a cupertino.orq MISC CUPERTINO /^,,(1 PLUMBING [:]MECHANICAL ELECTRICAL Lj MISCELLANEOUS O too v` PROJECT ADDRESS / D APN# OWNER NAME / PHONE L/D �J ^U y E-MAIL M �rl r j 2 aC mak ._r,�� ie e e_o,- STREET ADDRESS /O /°_ j / CITY, ATE,ZIP FAX t�-�c�/ k5.0/1 (f2 6 CONTACT NAME PHONE E-MAIL S� STREET ADDRESS CITY,STATE, ZIP FAX OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME LICEN$J1_7 1 s 7 LICEN TYPE ��- BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS /C/5 Co vvs CITY,STAT`L_ZIP � (n0 PHONE ARCHITECT/ENGINEJERI(NAME LICENSE NUMBERBUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF SFD or Duplex ❑ Multi-Family PROJECT IN WILDLAND PROJECT IN STRUCTURE: ❑ Commercial URBAN INTERFACE AREA ❑ Yes ❑ No FLOOD ZONE ❑ Yes ❑ NO DESCRIPTION OF WORK TOTAL VALUATION: / �� R$CBJVEDBY: By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to building construction. I authorize representatives of Cupertino to enter the above-identified property for inspection purposes. Signature of Applicant/Agent: Date: SUPPLEMENTAL INFORMATION REQUIRED OFFIck usEaN[Y lExrPss'� u Cfl 'tA L7 trA>l� MEPMiscApp_2011.doc revised 03/16/11