Construction Signoff Form.pdf

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CT4000 Construction Signoff Form This form is required to ensure the site for your ChargePoint EV charging station(s) has been prepared as specified, by you or by your chosen contractor, before beginning your charging station installation. Submit this completed form, and the photos specified at the end, to installdispatch@chargepoint.com. The detailed data sheets, site design guides, and installation guides defining ChargePoint specifications are online at:

chargepointuniversity.com.

IMPORTANT: All installations must comply with all applicable codes. ChargePoint provides concrete pedestal guidance in the CT4000 Site Design Guide that is applicable for most sites; however, the size for a given site might be different due to site conditions. Ensure site drawings have been completed and approved by a structural engineer for this site.

Note: If your station installer arrives to install your station and finds these items incomplete, you will incur a separate re-dispatch charge.

Site Information Contractor Information Site Address: Company Name:

Site Lead Name:

Number of CT4000 stations to be installed Pedestal: Wall:

Site Lead Job Title:

Contact Name: Site Lead Email:

Contact Phone: Site Lead Phone:

Contact Email: Date Work Began:

Take the following photos throughout the site construction process.

Required Pictures

1. Concrete pad showing anchor bolts, conduit, and wire for each station -or- Wall station location with flex conduit and wire for each station

2. Overall space around the concrete pad, showing all service clearances are available

3. The electrical panel’s specification label, to show total panel capacity

4. The open electrical panel with the dead front panel removed, showing terminations

5. The open electrical panel with the dead front panel on, showing breaker amperage ratings and labels for CT4000 connections

Sales Order Number (SO#)

Civil Work – Pedestal Mount

1. A new concrete pad was either designed and approved by a structural engineer for this specific site, or is a newly poured pad with:

• At least 600 mm (24 in) on each side, including underground.

• Follows one of the three recommended pedestal patterns in the Site Design Guide.

• Concrete 2500 PSI minimum.

-or- An existing concrete pad with:

• A minimum concrete volume of 0.23 m3 (8 ft3).

• A minimum concrete depth of least 150 mm (6 in) thick.

• Mounting bolts positioned at least 153 mm (6 in) from the edges of the pad when measured from the center of any bolt.

2. Three anchor bolts extend 75 mm +/- 6 mm (3 in +/- ¼ in) above the concrete, with two bolts in the front and one bolt behind the conduit stub-up. Bolts are plumb and secure in concrete or epoxy.

3. The center of the conduit stub-up (a) is at least 228 mm (9 in) from obstructions to the rear.

4. Conduit extends 300-600 mm (12-24 in) above the concrete.

5. Walls, fences, or slopes do not prevent water from draining from the pad.

a

Civil Work – Wall Mount

1. Conduit brings wire to the station.

2. 900 mm (3 ft) of wire is provided for installation.

Electrical Work

1. Electrical infrastructure has been completed in accordance with all applicable codes and ChargePoint specifications.

2. A dual-pole 40 A non-GFCI circuit breaker feeds each port (unless planning for Power Management).

3. Each circuit breaker is new or in good working order.

4. Breakers are correctly labeled in the panel.

5. Only bonded neutral systems are used.

System Type Select 120/240 VAC 1Ø bonded neutral 120/208 VAC 3Ø WYE bonded neutral 120/240 VAC 3Ø Delta center tap-grounded bonded neutral

6. The station mounting location has been tested for cellular coverage and shows an RSRP of -90 dBm or better (and an RSRQ of -10 or better).

Installation Readiness

1. All station boxes are delivered, available, and contents are undamaged.

2. If circuit sharing, the PowerShare Kit has been delivered (one kit per station).

I, , hereby certify that the scope of work in this form has been correctly completed.

Signature Date