B-2016-3223CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: B-2016-3223
18817 PENDERGAST AVE CUPERTINO, CA 95014-3620 (375 33 021)
DE BLEECKER
REGIEN D AND
GIELENS MARIE C
18817 PENDERGAST
AVE CUPERTINO CA
95014-3620
OWNER'S NAME: DE BLEECKER REGIEN D AND GIELENS MARIE C
DATE ISSUED: 12/07/2016
OWNER'S PHONE: 408-398-0154
PHONE NO: None
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License Class Lie. #
Contractor DE BLEECKER REGIEN D AND GIELENS MARIE C Date
X BLDG _ELECT _ PLUMB
f
I hereby affirm that I am licensed under the provisions. of Chapter 9 (Commencing
— MECH X RESIDENTIAL— COMMERCIAL
with Section 7000) of Division 3 of the Business & Professions Code and that my
license is in full force and effect.
JOB DESCRIPTION:
EV CHARGER IN GARAGE
I hereby affirm under penalty of perjury one of the following two declarations:
1. 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.
2. 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
permit is issued.
Sq. Ft Floor Area:
Valuation: $1000.00
APPLICANT CERTIFICATION
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
APN Number:
Occupancy Type:
and state laws relating to building construction, and hereby authorize
375 33 021
representatives of this city to enter upon the above mentioned property for
inspection purposes, (We) agree to save indemnify and keep harmless the
City of Cupertino against liabilities, judgments, costs, and expenses which
PERMIT EXPIRES IF WORK IS NOT STARTED
may accrue against said City in consequence of the granting of this permit.
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally, the applicant understands and will comply with all non -point
source regulations per the Cupertino Municipal Code, Section 9.18.
180 DAYS FROM LAST CALLED PECTION.
Signature Date 12/07/2016
Issued by: IVIELI A
Date: 12/07/2016
OWNER -BUILDER D R TION
I he e y affirm that I am exempt from the Contractor's License Law for one of the
RE -ROOFS:
follo " g two reasons:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
` 1. % I, as owner of the property, or my employees with wages as their sole
installed without first obtaining an inspection, I agree to remove all new materials for
compensation, will do the work, and the structure is not intended or offered for
inspection.
sale (Sec.7044, Business & Professions Code)
2. I, as owner of the property, am exclusively contracting with licensed
Signature of Applicant:
contractors to construct the project (Sec.7044, Business & Professions Code).
Date: 12/07/2016
I hereby affirm under penalty of perjury one of the following three declarations:
iALL
ROOF COVERINGS TO BE CLASS "A" OR BETTER
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.
HAZARDOUS MATERIALS DISCLOSURE
2. 1 have and will maintain Worker's Compensation Insurance, as provided for by
I have read the hazardous materials requirements under Chapter 6.95 of the
Section 3700 of the Labor Code, for the performance of the work for which this
California Health & Safety Code, Section 5505, 25533, and 25534. I will
permit is issued,
maintain compliance with the Cupertino Muni 'pal Code, Chapter 9.12 and the
s. I certify that in the performance of the work for which this permit is issued .I
Health & Safety Code, Section 25532, a) shoal I store or handle hazardous
shall not employ any person in any manner so as to become subject to the
material. Additionally, should I use equipment o devices which emit hazardous
air contaminants as defined by the Bay Area Air uality Management District I
Worker's Compensation laws of California. If, after making this certificate of
will maintain compliance with the Cu ertin M 'cipal Code, Chapter 9.12 and
exemption, I become subject to the Worker's Compensation provisions of the
the Health & Safety Code, o s 25 05, 25533, and 25534.
Labor Code, I must forthwith comply with such provisions or this permit shall
be deemed revoked.
Owner or authorized agent: c
APPLICANT CERTIFICATION
Date: 12/07/2016
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
I hereby affirm that there is a construction lending agency for the performance
relating to building construction, and hereby authorize representatives of this city
of work's for which this permit is issued (Sec. 3097, Civ C.)
to enter upon the above mentioned property for inspection purposes. (We) agree
Lender's Name
to save indemnity and keep harmless the City of Cupertino against liabilities,
judgments, costs, and expenses which may accrue against said City in
Lender's Address
consequence of th ting of this permit. Additionally, the applicant understands
and will comply wit n -point source regulations per the Cupertino Municipal
ARCHITECT'S DECLARATION
Code, Section 9.18.
1 understand my plans shall be used as public records.
V
ALTERNATIVE ENERGY PERMIT APPLICATION
its COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 AE
CUPERTINO (408) 777-3228 • FAX (408) 777-3333 • building(Dcupertino.org
-ZAl L 3 Z Z
PVApp_2011. doc revised 03116111
PROJECT ADDRESS 19311 x m606;JR O L AVE
APN # 3 .p ` 3 - ,o 2j /
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OWNER NAME - rULG'
319 V�
STREETADDRESS /pSJ�l -y yyyy�®^yA 6
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CITY,. STATE, ZIP Wpns-O p-IOV0 ) J,
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-
FAX
CONTACT NAME fl4U
L®®L�.Y`®
PHONE Cfo rj �J�" q ®l�
EMAIL..®"rT.cw'
STREET ADDRESS" 11 9917 Icy /� a ®
11
CITY, STATE, ZIP ��r jA)0 6A FAX
❑ OWNER J�'! OIWNER-BUILDPER�M1['❑KJ�OEWNERAGENTT ❑ CONTRACTOR ❑ CONTRACTOR .AGENT 11 ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTORNAME , awn!V,
`�/(�
ICENSE NUMBER 7
LICENSE TYPE
BUS. LIC #
COMPANY NAME
E-MAIL _
FAX - -
STREET ADDRESS -
CITY, STATE, ZIP
PHONE
ARCHITECT/ENGINEER NAME
LICENSE NUMBER
BUS.. LIC #
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE -
USE OF SFD or DUpl.. ❑ Iblulti-Family
STRUCTURE: ❑. Commercial
PROJECT IN WILDLAND -/
URBAN INTERFACE AREA [I Yes ice' NO
PROJECT IN
FLOOD ZONE El Yes �.
ElSOLAR PANELS
2 ELECTRIC VEHICLE CHARGING STATION TO
SOLAR WATER HEATING
El OTHER:
FOR SOLAR PANELS. NUMBER OF PANELS/UNITS:
KILOWATTS (COMMERCIAL ONLY):
TOTAL VALUATION/G,
DESCRIPTION OF WORK Avo rind or aWm- mg/f Z9 y
wwopcw ! ,.
By my signature below, I certify to each of the follo ing: I am the property owner or authorized agent to act on the property owner's behalf. I have read flus
application and the information I have provi orrec 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 buil ' ctio authorize representatives of Cupertino to enter the above -identified property for inspection purposes.
Signature of Applicant/Agent: Date:
SUP LEMMa
j
14�
ATION REQUIRED
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PVApp_2011. doc revised 03116111
OWNER -BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • building(ftupertino.ora
Dear Property 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:
SITEADDR(
AVE
APN
BP#
OWNER NAME
C OW R A RRE61a) _111F IS (r`
}}.
DESCRIPTION OF WORK: 'T OP
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.)
4il1. I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner -
der" 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
on 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.
2. 1 understand building permits are not required to be signed by property owners unless they are responsible for
t 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. l understand that I may
prgtect myself from potential financial risk by hiring a licensed Contractor and having the permit filedin his or her
e 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.
5. 1 understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the
tol'i value of my construction is at least five hundred dollars ($500), including labor and materials, I may be
nsidered an "employer" under state and federal law.
6. 1 understand if I am considered an "employer" under state and federal law, I' must register with the state and
fe ral 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
Idreential
serious financial risk.
7. 1 understand under California Contractors' State License Law, an Owner -Builder who builds single-family
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
a performed under contract with a licensed general building Contractor.
JorAJ
8. I understand as an Owner -Builder if I sell the property for which this permit is issued, I may be held liable for
a ' financial
personal injuries sustained by any subsequent owner(s) that result from any latent construction
defects in the workmanship or materials.
OwnerBuilderFonrl 2010.doc revised 04114110
J1_ understand I may obtain more information regarding my obligations as an "employer" from the Internal
nue 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
C ractors.
44 10. I am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I
a the party legally and financially responsible for proposed construction activity at the site address listed above.
11. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide
b9701 applicable laws and requirements that govern Owner -Builders as well as employers.
12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the
U
4infmation l have provided on this form. Licensed contractors are regulated by laws designed to protect the public. If
ontract 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, his form must be completed and signed by the property owner and
returned to the agency responsible r iss ing the permit. Note: A copy of the property owner's driver's license,
form notarization, or other verification . t le to the city may be required to be presented when the permit is issued
to verifythe pro ert owner's si
Property Owner's Signature -Date: ; ' ,' D
-- ------------------- ---------------------- -----------------------------------------------------------------------------------------
(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:
Address of Authorized Agent:
Tel No
I declare under penalty of perjury that l 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:
OwnerBuilderForm 2010.doc revised 04/14/10
V�
-.-Iectrical Proposed
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8` 2 SIT
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UPER IN
Guiiding DePa;rtnen,
DEC 0 7 2016
REVIEWED COMPLIANCE
Reviewed By.
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PLOT Y i LANS CHECKED ' T
U-AA(e-
DATE l2- 7 Vr
COM�3UNITY DEV L r UME.NT
BUILDIi��
Dl\I- - L1lN0
APPROVED
This set of plans and specifications MUST be kept at the
job site during construction. It i�: unlawfui to make any
changes or a".orations 01-+ same, or to deviate
tr arefrom, wit,�c-1i p3prcvai fro r t` e 3uilding Official.
Ti'�2 Stamping of ,t - plan and spec ,c�' `..s SHALL NOT
he held to pernat u a �, pro.. al of the violation
a r r,- �« _ di'�Ur ,-.e i,r Slate Law.
IT E
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Notes:—__
2 Addition of Hardwired EV
Level 2 Charging Station 240V
32A
Propose Charging Station
ChargePoint 220V; 32A
(Model CPH25-L18)
Page 2/2
Electrical Permit Application — 18817 Pendergast Ave
Residential Project Cover Sheet
- Assessor's Parcel Number: 375-33-21 (Zone R1-5)
- Name of Owner: Regien De Bleecker— Marie Gielens
- Project Address: 18817 Pendergast Av Cupertino CA95014
- Contact Person: Regien De Bleecker — 408-398-0154/408-320-2025
Marie Gielens — 408-821-3255/408-320-2025
- Net Square Footage of Lot: 5,314 sqft
Square Footage: Existing Proposed
First Floor 1543.4 ft^2 1.543.4 ft^2
Second Floor 857.1 ft^2 857.1 ft^2
Garage 446.0 ft^2 446.0 ft^2
Total 2846.5 ft^2 2846.5 ft^2
Are there at least two 10 foot by 20 foot clear spaces inside the garage: Yes
- Is privacy protection planting required for the project: No
- On what floor is the work done? Yard
- Brief description of work: Electrical
- Code Editions:
2013 CBC (Y -N) 2013(Y -N) 2013 CMC (Y -N)
2013 CPC (Y -N) 2013 ¢g (Y -N)
California Green Building Stas : ,qc 2013 Juildrrty � a�
° j F,
DEC
�errf
2016
Review � Yom; r�:� Page 1/2
Specifications and Ordering information
Ordering information
Specify model number Followed by the applicable code(s).
Model Hardwire, 16A,12 RPH* 3657 mm (121) card
CPH12-Li2
Plug, 16A,12 RPH, 3657 mm (12') cord
CPH12-L12-P
Hardwire, 32A, 25 RPH, 5486.4 mm (18') cord
CPH25418
Plug, 32A, 25 RPH, 5486.4 mm (18) cord
CPH25-L18-P
Hardwire, 32A, 25 RPH, 7620 mm (25') cord
CPH25-L25
Plug, 32A, 25 RPH, 7620 mm (25') cord
CPH25-L25-P
Replacement _ : 3657 mm (12) 16A Charging Cord :'
CPHI2CORD LT2 F . .
Cord =5486.4 mm (18') ,32A Charging or. ,
CPH25CORD L78 F
;_7620 orris (25) 32A Charc��jh Cord _
,CPH25CORD L23
'RPH: estimated, maximum miles of Range Per Hour the station can deliver
ChargePoint Home
ChargePoint Horne
Dimensions
28
2 chargepoint.com
178 mm
' 125.9 mm
AA
Specifications
Connector and Electrical
Input Cofcj� Ni 1�A i1(32A S�atlon)r NEMA 20 {16A sfation) ,
AC Power Output Rating 7.7kW (240V AC " 32A) or 3.8kW (240V AC16A).
AG Rower Input RatingAUGtiI
n5..... - . 208/2�}OV az single phase @32k6 16A
Required Service Panel Breaker Dedicated Dual Pole 40A (32A station) or Dual Pole 20A (16A station)
Service Pattej CiFCI Do Clot provide exterpal GFCI as 1t CY ay conflict with mteCnaa GFCI,CC1D)
Power Wiring 3 Wire - L1, L2 plus Earth (no neutral)
t C}t�gll]g Cord Lengths aid �impdages 17620 mm (25) 32A, 5486 4 mm 1181W —) 32A artd,365. � mm (�2 )1
_..__.�_.-...,,.... �.
i�.„3 .
Connector Type SAE J1772”
poyveY Measu ernent c c +J 2 0 r6 f�orp 2%-9to tyli scal6L.(32
A)
Nr:,
Power Report/Store Interval 13 minute aligned to hour
Safety and Connectivity Features
Grourii fault Deteaolt 120rnA CC1D with autoretry
Open Safety Ground Detection Continuously monitors presence of safety (green wire) ground connection
Plu (tut Detectlon Power term natQd per SAE J1772 s e'ciflcatlo s
_ y
�24
-jig
i7
Local Area Network 2.4/5 GHz Wi-Fi (802.11 a/b/g/n)
Safety and Operational Ratings
Indicators
ChargePoint, Inc. reserves the right to alter product offerings and specifications at any time without notice, and is not responsible for typographical or graphical errors that may
appear in this document.
chargepolnt.com 3