13100124CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10675 MINETTE PL
CONTRACTOR: NIKUNJ & GOLDA
PERMIT NO: 13100124
BANSAL
OWNER'S NAME: NIKUNJ & GOLDA BANSAL
10675 MINETTE PL
DATE ISSUED: 10/17/2013
OWNER'S PHONE: 4084804250
CUPERTINO, CA 95014
PHONE NO:
JOB DESCRIPTION: RESIDENTIAL COMMERCIALEI
13 LICENSED CONTRACTOR'S DECLARATION
INSTALLATION OF EVC STATION LOCATED IN GARAGE
License Class Lc. #
5KW
Contractor Date
I 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.
I 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: $500
I have and will maintain Worker's Compensation Insurance, as provided for by
APN Number: 37532038.00
Occupancy Type:
Section 3700 of the Labor Code, for the performanceof the work for which this
permit is issued.
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
WIT 180 DAYS OF PERMIT ISSUANCE OR
to building construction, and hereby authorize representatives of this city to enter
180 DS ROM LAST CALLED INSPECTION.
upon the above mentioned property for inspection purposes. (We) agree to save
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
City in of the
I� �/
costs, and expenses which may accrue against said consequence
Issued bj4s 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 Date
All roofs shall be inspected prior to any roofing material being installed. If a roof is
installed without first obtaining an inspection, I agree to remove all new materials for
inspection.
OWNER -BUILDER DECLARATION
Signature of Applicant: Date:
I 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 notintended 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
I 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
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
performance of the work for which this permit is issued.;
1 have and will maintain Worker's Compensation Insurance, as provided for by
the Health &Safety Code, Secti s 2550 533, and 5534.
t3 ��
Section 3700 of the Labor Code, for the performance of the work for which this
Owner or authorized agent: Date:
permit is issued.
certify that in the performance of the work for which this permit is issued, I shall
41
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
I
I hereby affirm that there is a construction lending agency for the performance of
become subject to the Worker's Compensation provisions of the Labor Code, must
work's for which this permit is issued (Sec. 3097, Civ C.)
forthwith comply with such provisions or this permit shall be deemed revoked.
P y p P
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
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
I understand my plans shall be used as public records.
granting 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.
Date I lJ�'
Signature
CONSTRUCTION PERMIT APPLICATION Z�
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION v�
10300 TORRE AVENUE • CUPERTINO, CA 950143255 \b
GUPERTiNO (408) 777-3228 • FAX (408) 777-3333 • buildingancupertino.org
❑ NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION / TI ❑ REVISION / DEFERRED ORIGINAL PERMIT #
PROJECr ADDRESS 1067S M I MET T L PL •,C:vP (INS, TAPII
k
OWNERNAME
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PHO E-MAIL
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STREET ADDRESS CITY. STATE, ZIP FAX
106 m N_ L C0 /Vo o 1
CONTACT NAME
PHONE
E -MAB.
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ST ADDRESS
CITY,PLZIPSIAT�((N Q
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m OWNER ❑ OWNER -BUB -DER ❑ OWHERAGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHTIECT 13 ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTORNAME�E
Li NUMBERS
7
LICENSE TYPE
BUS. LIC #
6
c�_ I C)
COMPANY NAME
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FAX
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srREe�nD DRESS
CITY, STATE, ZIP
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PHONE - 2
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DIC
ARCHITECTIENGINEER NAME
LICENSE NUMBER
BUS. LIC #
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CrrY, STATE, ZIP
PHONE
DESCRIPTION OF WORK ., t _ �
or CT
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C - Q LSC- t
EXISTINGUSE
PROPOSIDUSE CONSrILTYPE
#STORIES
USE
TYPE
OCC.
SQ.FT.
VALUATION (S)
EXLSTG
NEW FLOOR
DEMO
TOTAL
AREA
AREA
AREA
NETAREA
BATHROOM
IOTCHEN
OTHER
REMODEL AREA
REMODELAREA
REMODEL AREA
PORCHAREA
DECKAREA
TOTAL .DECIGPORCHAREA
GARAGE AREA: DErACH
ATTACH
# DWELLING UNITS:
IS A SECOND uNrr 3 YES
SECOND STORY DYES
BEINGADDBD! [3NO
ADDITIONS ONO
PRE -APPLICATION DYES IFYES.MOVIDECOPYOF
ISTHEBLDGAN Oyaj
REC
TOTAL ON:
PLANNINGAPPL# E]NO P"MIGAPPROVALLETTER
EICHLERHOME! []NO
,
CJ�t(l�(T
By my signature below, I certify to each of the following: t am the property owner authorized ag;Tt t act on the property owner's behalf. I have read this
application and the information I have providq4 is correct I have rC4d the Description of Work and v it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to b. ` ` g nstructiom I auth ' representatives of Cupertino to enter the above -identified property for inspection purposes.
Signature of Applicant/Agent: Date- 0 16 Z b
SUPPLEMENTAUINFORMATIM REQUIRED
PLANCHECKTYPE
ROUTING SLIP
New SFD or Multifamily dwellings: Apply for demolition permit for
_
existing building(s). Demolition permit is required prior to issuance of building'
a_rW cotmrtER
sLm Dnvc ICON REVIEW
permit for new building.
❑ EXPRESS
LANNING PLAN REVIEW
Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
❑ STANDARD
❑ PUBLTC WORKS
_
Yo—if any Hazardous Materials the being used as part of this project.
❑ LARGE
❑ I= DEPT
_ Copy of Planning Approval Letter or Meeting with Planning prior to
❑ MAJOR
❑ SANITARY SEWERDiSTRICT
submittal of Building Permit application.
-
❑ ENMONMENTAL UFALTH
BldgApp 2011.doc revised 06/21/11
CUPERTINO
OWNER -BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION
10300 TORRE AVENUE - CUPERTINO, CA 95014-3255
(408) 777-3228 - FAX (408) 777-3333 - buildinona.cupertino.org
Dear Properly Owner(s):
An application for a building permit has been submitted in your name listing yourself as the builder of the property
improvements specified at:
SITE ADDRESS 1064� MI %Mt (
2J /�i0 7�
APN
BP#
OWNER NAME Nit wqT �Yn ivs&
OWNER ADDRESS
DESCRIPTION OF WORK:
W
We are providing you with an Owner -Builder Acknowledgment and Information Verification Form to make you aware of
your responsibilities and possible risk you may incur by having this permit issued in your name as the Owner -Builder. We
will not issue a building permit until you have read, initialed your understanding of each provision, signed, and
returned this form to us at our official address indicated. An agent of the owner cannot execute this notice unless
you, the property owner, obtain the prior approval of the permitting authority.
OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION
(DIRECTIONS: Please read and initial each statement below to signify you understand or verify this information.)
W1. I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner -
Builder" building permit that erroneously implies that the property owner is providing his or her own labor and material
personally. I, as an Owner -Builder, may be held liable and subject to serious financial risk for any injuries sustained by
an unlicensed person and his or her employees while working on my property. My homeowner's insurance may not
provide coverage for those injuries. I am willfully acting as an Owner -Builder and am aware of the limits of my
insurance coverage for injuries to workers on my property.
C4-2. 1 understand building permits are not required to be signed by property owners unless they are responsible for
the construction and are not hiring a licensed Contractor to assume this responsibility.
3. 1 understand as an "Owner -Builder" I am the responsible party of record on the permit. I understand that I may
protect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her
name instead of my own.
4. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license
numbers on permits and contracts.
QL-5. I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the
total value of my construction is at least five hundred dollars ($500), including labor and materials, I may be
considered an "employer" under state and federal law.
Q6. 1 understand if I am considered an "employer" under state and federal law, I must register with the state and
federal government, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to
unemployment compensation for each "employee." I also understand my failure to abide by these laws may subject
me to serious financial risk.
a-7. I understand under California Contractors' State License Law, an Owner -Builder who builds single-family
residential structures cannot legally build them with the intent to offer them for sale, unless all work is performed by
licensed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work
is performed under contract with a licensed general building Contractor.
(A--8. I understand as an Owner -Builder if I sell the property for which this permit is issued, I may be held liable for
any financial or personal injuries sustained by any subsequent owner(s) that result from any latent construction
defects in the workmanship or materials.
OwnerBuilderFonn 2010.doc revised 04/14/10
9. I understand I may obtain more information regarding my obligations as an "employer" from the Internal
Re enue Service, the United States Small Business Administration, the California Department of Benefit Payments,
and the California Division of Industrial Accidents. I also understand I may contact the California Contractors' State
License Board (CSLB) at 1-800-321-CSLB (2752) or www.cslb.ca.gov for more information about licensed
contractors.
-10.1 am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I
the party legally and financially responsible for proposed construction activity at the site address listed above.
�,L11. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide
by all applicable laws and requirements that govern Owner -Builders as well as employers. .
N 12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the
information I have provided on this form. Licensed contractors are regulated by laws designed to protect the public. If
you contract with someone who does not have a license, the Contractors' State License Board may be unable to
assist you with any financial loss you may sustain as a result of a complaint. Your only remedy against unlicensed
Contractors may be in civil court. It is also important for you to understand that if an unlicensed Contractor or
employee of that individual or firm is injured while working on your property, you may be held liable for damages. If
you obtain a permit as Owner -Builder and wish to hire Contractors, you will be responsible for verifying whether or not
those Contractors are properly licensed and the status of their workers' compensation insurance coverage.
CONSTRUCTION LENDING AGENCY
(DIRECTIONS: Please complete the following construction lending agency information.)
I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued
(Sec 3097 Civ.)
Lender Name: Lender Address:
Before a building permit can be issued, this form must be completed and signed by the property owner and
returned to the agency responsible for issuing the permit. Note: A copy of the property owner's driver's license,
form notarization, or other verification acceptable to the city may be required to be presented when the permit is issued
to verify the property owner's si nature.
Property Owner's Signature: 6a V Date:
---------------------------------------------------------------------------------------------------------------------------------------------
(NOTE: The following Authorization Form is required to be completed by the property owner only when designating an
agent of the property owner to apply for a construction permit for the Owner -Builder).
AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF
Excluding the Notice to Property Owner, the execution of which I understand is my personal responsibility, I hereby
authorize the following person(s) to act as my agent(s) to apply for, sign, and file the documents necessary to obtain an
Owner -Builder Permit for my project.
Scope of Construction Project (or Description of Work):
Project Location or Address:
Name of Authorized Agent: Tel No
Address of Authorized Agent:
I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the
above information and certify its accuracy. Note: A copy of the property owner's driver's license, form notarization, or other
verification acceptable to the city may be required to be presented when the permit is issued to verify the property owner's
signature.
Property Owner's Signature:
Date:
OwnerBuilder Fo77n 2010.doc revised 04/14/10
EV Charging Dock
Aerovironment
Model EVSE-RS
0
23'.5 10
evse rs - charging dock
40amp-240-volt
Garage
Main Garage Door Ix
Q M
Customer Nninkung Bansal
1{'
Project
Date
EV Charging Dock
10/16/1,
Prepared by
J. Dollens
1 of 1
co
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5,
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8-2 Romex.
ampacity 40A
Gnd 10 ga.
approx 35ft
21 PLOT' P LAA,5
CHECKED gy
GATE C 7
LANNI DEPT.
DATE
BLDG, DEPT
I panel
I I
I 200A
I I
I L1 N L2 G
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I
40A ) ) 40A
-- —_J
CUPERTINO
Sui!ding Department
OCT 17 2013
REVIE'A'ED FOR CODE vOMPLIANCE
Reviewed By:
S R#
Customer Nninkung Bansal
10675 Minette PI. Cuperti
Project
Date
EV Charging Dock
10/16/1,
Prepared by
J. Dollens
1 of 1
MIDM61ftensl9leebic torp.
Troubleshooting - Panel Upgrades - Solar Power
,--, 408-929-6100 - fixmypower.com
o,
REVIEWED FOR CODE COMPLIANCE
Reviewed By:
This guide is a reference for Municipalities inquiring about the use, installation and compliance of
the AeroVironment EVSE-RS with the National Electric Code and Local Codes.
AeroVironment, Inc. Model EVSE-RS
Product and Installation Overview
The EVSE-RS is a device which offers a simple and safe way of providing electricity to the
on -board charger in an Electric Vehicle.
NEC 625 Compliance
• 625.2 Definitions.
• Personnel Protection System: A system of personnel protection devices and
constructional features that when used together provide protection against electric shock
of personnel.
• 625.5 Listed or Labeled: UL Listed 2594
• 625.9 Electric Vehicle Coupler: J1772 coupler SAE North American standard
• 625.13 Electric Vehicle Supply Equipment: Permanently connected and fastened in
• Place. No exposed live parts
• 625.14 Rating: 30 amp output rating. Continuous load
• 625.15 Markings:
— (A) For Electric Vehicle Use Only (Denoted on EVSE-RS Label)
— (B) Ventilation not required (Denoted on EVSE-RS Label)
• 625.16 Means of Coupling: Conductive J1772 connector and EVT rated cable
• 625.17 Cable: EVT rated cable extra heavy usage
• 625.18 Interlock: Proximity switch de -energizes when unplugged
• 625.19 Automatic De-Energization of Cable: Cable break away feature.
• 625.21 Over current Protection: Shall be sized for continuous duty 125 % - 40A Circuit
Breaker
• 625.22 Personnel Protection System: Proximity switch, GFI protection, Breakaway cable,
Trouble annunciation light for faults and NEMA 3 Rain Tight enclosure.
• 625.23 Disconnecting Means: For electric vehicle supply
• equipment rated more than 60 amperes or more than 150
• volts to ground, the disconnecting means shall be provided
• and installed in a readily accessible location.
• 625.25 Loss of Primary Source: Contactor opens upon loss of power.
INSTALLING THE
EVSE-RS
Specifications:
■ For use with Electric Vehicles
■ Ventilation not required
■ NEMA Type 3 Rain Tight enclosure
■40 Amp. circuit breaker rating. Do NOT use a Class A circuit breaker with the
EVSE-RS Charging Dock.
to +50
loll
Power Disconnect switch Charging Dock
distribution (if applicable)
panel Wall stud
am
4H 4 LOW
INSTALLATI
t4
1. Choose wire entry location
HOLE ON UNDERSIDE OF CHARGING DOCK
Bottom View
2. Attach the mounting plate
Mounting plate
o e
Large hole for conduit utility wires
Charging Dock mounting holes
o Small holes for
-® mounting plate
to wall stud
Wall stud
48"
HOLE IN REAR OF
CHARGING DOCK
Rear View
O Flat washer Lag bolt
OO 00--- ------------------ -------
0 0
0 0.----- ---------------- Q -------
�
0
Wall stud
I Attach the Charging Dock to the mounting plate
a. Torque the screw to 40 in/Ib.
Upper mounting hole
Flat washer Socket head screw
------ @�------------em❑
4. Wire the Charging Dock
a. Torque the terminal block screws to 20 in/Ib.
b. Torque the Grounding Strip screws to 20 in/Ib.
Terminal Block
Ground Strip
Ground Wire
Two power wires
5. Install the front cover
#10 Torx screws— Torque 12in/Ib
i
1 It
E r
= 4 ® 4M
t
Removing the trim ring
Access We Outer ring
6. Complete the installation
c
i
GO
O
i
FRONT PANEL COMPONENTS
POWER PRESENT
The charging dock is receiving
AC power.
READY TO CHARGE
The charging dock is ready to
charge or charging is paused.
VEHICLE CONNECTED
The connector is properly
connected to the vehicle port
or the charge is complete.
VEHICLE CHARGING
The vehicle is being charged.
TROUBLE
There is an error. Try removing
the connector and Inserting back
into the vehicle. If Trouble
Indicator is still illuminated call
Customer Service at 1 (877) NO
GAS EV or 1 (877) 6642738 or
visit Customer Service on the
web at www.nissanusa.comAeaf.
START
Press to begin a charge. The
POWER PRESENT and READY
TO CHARGE lights must be on.
STOP
Press to manually stop charging.
The device will stop automatically
when it reaches full charge.
RELEASE BUTTON
Press to release the Connector
from the charging dock or the
vehicle port.
CHARGING THE VEHICLE
v
Press the button on the
connector to release It
from the charging dock.
Insert connector finrdy Into the
vehicle charge port Man
fully inserted, the VEHICLE
CONNECTED light on the
charging dock will dlurrunate.
i
L5J
Charging will stop automatically
when complete. You can manually
stop changing by pressing STOP.
When the READY TO CHARGE
light blinks, remove the connector
from the vehicle charge port. N
you have pressed STOP. you can
press START to resume charging.
v
Unwrap the cable from
around the cable hanger.
67
When the VEHICLE
CHARGING light stops
blinking on the charger.
press the button on the
connector to release.
Pull to remove from
vehicle charge port
v
roMainneeart 0 "---'
aeAovroormar! o
Charging will begin
eurxemracxn *
automatically. When
o
charging begins, the
o
VEHICLE CHARGING light
will begin to blink. There
Is no need to press START.
67
When the VEHICLE
CHARGING light stops
blinking on the charger.
press the button on the
connector to release.
Pull to remove from
vehicle charge port