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S*,FFot�� �o�o. coGy Town of Southold 4/8/2024 a - P.O.Box 1179 o 53095 Main Rd oy� ao� Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 45117 Date: 4/8/2024 THIS CERTIFIES that the building ACCESSORY Location of Property: 2800 Camp Mineola Rd,Mattituck SCTM#: 473889 See/Block/Lot: 123.-5-4 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 1/26/2024 pursuant to which Building Permit No. 50398 dated 3/7/2024 was issued,and conforms to all of the requirements of the applicable provisions of the law. The occupancy for which this certificate is issued is: EV chargerpplied for. The certificate is issued to Boyle,Donald&Kathlyn of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 50398 3/29/2024 PLUMBERS CERTIFICATION DATED Xf Authoriz d Si ature TOWN OF SOUTHOLD BUILDING DEPARTMENT y x TOWN CLERK'S OFFICE "oy SOUTHOLD, NY BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES WITH ONE SET OF APPROVED PLANS AND SPECIFICATIONS UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) Permit#: 50398 Date: 3/7/2024 Permission is hereby granted to: Boyle, Donald 2800 Camp Mineola Rd Mattituck, NY 11952 To: install EV charger as applied for. Charger must be located a minimum of 10' from lot lines. i At premises located at: 2800 Camp Mineola Rd, Mattituck SCTM # 473889 Sec/Block/Lot# 123.-5-4 Pursuant to application dated 1/26/2024 and approved by the Building Inspector. To expire on 9/6/2025. Fees: ACCESSORY $125.00 ELECTRIC $100.00 CERTIFICATE OF OCCUPANCY $100.00 Total: $325.00 Building Inspector off' pr SOUry�! � o Town Hall Annex Telephone(631)765-1802 54375 Main Road P.O.Box 1179 G Southold,NY 11971-0959 �ly� sean.deviinCaD-town.southold.ny.us DUffN, BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICAL COMPLIANCE SITE LOCATION Issued To: Donald Boyle Address: 2800 Camp Minneola Rd city,Mattituck st: NY zip: 11952 Building Permit#: 50398 Section: 123 Block: 5 Lot: 4 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: Electrician: Absolute Electric License No: 62784ME SITE DETAILS Office Use Only Residential X Indoor Basement Service X Commerical Outdoor X 1st Floor Pool New X Renovation 2nd Floor Hot Tub Addition Survey X Attic Garage INVENTORY Service 1 ph X Heat Duplec Recpt Ceiling Fixtures Bath Exhaust Fan Service 3 ph Hot Water GFCI Recpt Wall Fixtures Smoke Detectors Main Panel 200A A/C Condenser Single Recpt Recessed Fixtures CO Detectors Sub Panel 100A A/C Blower Range Recpt Ceiling Fan Combo Smoke/CO Transfer Switch UC Lights Dryer Recpt Emergency Strobe Heat Detectors Disconnect 200A Switches 4'LED Exit Fixtures Sump Pump Other Equipment: 200A Service Disconnect(1), 100A Exterior Panel 20 Circuits /4 Used, 30A for pool & 50A for Car Charger Notes: 300A Service w/ 200A for House & 100A Exterior Panel Inspector Signature: Date: March 29, 2024 S.Devlin-Cert Electrical Compliance Form(1) o��OF SOUT��I � o Town Hall Annex Telephone(631)765-1802 54375 Main Road P.O.Box 1179 G Q sear.devlin(,S-town.southold.ny.us Southold,NY 11971-0959 �Ycoum,� BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICAL COMPLIANCE SITE LOCATION Issued To: Donald Boyle Address: 2800 Camp Mineola Rd city:Mattituck st: NY zip: 11 Building Permit#: 50398 Section: 123 Block: 5 Lot: 4 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL.ELECTRIC CODE Contractor: Electrician: Absolute Electrical Contr. License No: 62784ME SITE DETAILS Office Use Only Residential X Indoor X Basement Service Commerical Outdoor X 1st Floor Pool New X Renovation 2nd Floor Hot Tub Addition Survey Attic Garage INVENTORY Service 1 ph Heat Duplec Recpt Ceiling Fixtures Bath Exhaust Fan Service 3 ph Hot Water GFCI Recpt Wall Fixtures Smoke Detectors Main Panel A/C Condenser Single Recpt Recessed Fixtures CO Detectors Sub Panel A/C Blower Range Recpt Ceiling Fan Combo Smoke/CO Transfer Switch UC Lights Dryer Recpt Emergency Strobe Heat Detectors Disconnect 50A Switches 4'LED Exit Fixtures Sump Pump Other Equipment: Carcharger (Pump Style) 50A 50A Breaker for Car Charger Notes: EV Charger Inspector Signature: Date: March 29, 2024 S.Devlin-Cent Electrical Compliance Form *OF SOUjyO� # # TOWN OF SOUTHOLD BUILDING DEPT. 631-765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] INSULATIOWCAULKING [ ] FRAMING /STRAPPING jv'j"FINAL L,-:V [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION '� [ ] PRE C/O [ ] RENTAL REMARKS: Q��(�Z•!G� Ce �I� .G / DATE 3- 2 INSPECTOR OF SOUTyO� 57 # # TOWN OF SOUTHOLD BUILDING DEPT. o �0 631-765-1802 INSPECTION [ ] FOUNDATION 1 ST/ REBAR [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] INSULATION/CAULKING [ ] FRAMING /STRAPPING [ ] FINAL ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ .] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) ELECTRICAL (FINAL) [ ] CODE VIOLATION [� ] PRE C/O [ ]. RENTAL r REMARKS: s� np( 4—;j ej (f C, — ok DATE G INSPECTOR FIELD INSPECTION REPORT DATE COMMENTS � b FOUNDATION (1ST) - W ----------------7------------------- FOUNDATION (2ND) � n W z � o � y ROUGH FRAMING& PLUMBING INSULATION PER N.Y. - a STATE ENERGY CODE C FINAL ADDITIONAL COMMENTS U 3 C:o '� 3-- Etc C��-�• _ �Z rn _ _ z -- a x ro a TOWN OF SOUTHOLD—BUILDING DEPARTMEN1 Town Hall Amex 54375 Main Road P.O.Box 1179 Southold,NY 11971-0959 Telephone(631)765-1802 Fax(631)765-9502 httDs://www.southold'owoLaff Date Received APPLOCAMN FOR BUOLMNG PERMT C E 0 V E r office Use Only PERMIT NO. Building Inspector: JA 2 6 2024 t9pPIc 0j'I 0 1 ei I n. q,D rlwl m: 'Tt cat`� owl "AU�e;5 Date: sam#i0oo- 4.__M- a-4-iA Phone#: ... Email I Mallfn Address: 9 ;f.,7ca. V 0.Ald gg gg� Name: --------------- Mailing Address: Phone#: Email: .......... Name: Mailing Address: Phone#: Email: N ajm; MN M Mailing Address: Phone#: C).. Email- ........ R E]NewStructure EffAddition E]Alte EIRepair DDemolition EsUff�ated Cost of Project: rat'o 00__ E]Other�?,v Cknavqe,,( qidi-L RM Will the lot be re-graded? E]Yes-ONo Will excess fill be removed frc m premises? E]Yes tKNO ':<':: - �.4:;' 'h,r�.:. �'�•t:.`sT mac:: -- 'k-"t':' Ja.,- .=,irV:�-:a,:z;r - ;;;..'t :-.�;::;:,,it"-':;�tti:%:�,::r'" :.5 :t�ti"�:"•�Y:3;,,i•.'-c...;F.r.-•-:;3� .._;�,~r,s v�ir";`.i;. 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"�� i: ^3,`�2 'z-.• s.� - ;5,: I.:,, w „g_ d vre�u tiorisan�;Wad rtautho?riiedlnsF�tofsSo:p'rei6�aniU� 'b'uililMng(s�;fnrnee`essaryii�s`peefans5 'Ir4sbt"e`meMamadefiereio;are�;:, ��gnishati(ejas;'�Uass�A'miSilemeanoi�purgoarl�;to5ettioiii230:�Sof.,tlteSNevwYorliState,Renatkaw.:;t���=, •,�•y�';�s+:,y ,y�'� :.,• _ �'`• � „�`; - Application Submitted By tint name): o w/AG D �- �'/L� DAut orized Agent Vowner Signature of Applicant: ��-�-Q-� Date: / l Z a '2 Ll STATE OF NEW YORK) COUNTY OF J 6 A n.(,j e - �oC being duly sworn,deposes and says th t(s)he is the applicant (Name of individual signing co ract)above named, i (S)he is the (Contractor,Agent,Corporate Officer,etc.) of said owner or owners,and is duly authorized to perform or have performed the said work nd to make and file this application;that all statements contained in this application are true to the best of his/her knowledge and belief;and that the work will be performed in the manner set forth in the application file therewith. Sworn before me this _ day of o J G u 20 I Notary Pi iblic Re ecca A. Lucak N tary Public, State of New York PROPERTYOWNER�18T�®6tl���e®h� Reg. No. 01 LU6386882 (Where the applicant is not the owner) QUalifiE din Suffolk County Commissi n Expires"02/04/2027 I, residing at do hereby authorize to apply on my behalf to the Town of Southold-Building Department for approval as described herein. Owner's Signature Date Print Owner's Name 2 BUILDING DEPARTMENT-Electrical Inspector TOWN OF SOUTHOLD Town Hall Annex-54375 Main Road -PO Box 1179 Southold, New York 11971-0959 �yjf; p Telephone(631) 765-1802- FAX(631) 765-9502 iameshCc�southoldtownny.gov—seand(M-southoldtownny.gov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (Ali information Required) Date: 2/5/2024 Company Name: Absolute Electrical Contracting and Designs Electrician's Name: Dominic Chizzoniti License No.: ME-62784 Elec. email:information@absolutec-d.com Elec. Phone No: 516-586-3050 01 request an email copy of Certificate of Compliance Elec. Address.: 27 Cain Drive Plainview, NY 11803 JOB SITE INFORMATION (All Information Required) Name: Donald Boyle Address: 2800 Camp Mineola Road Mattituck, NY 11952 Cross Street: Camp Mineola Road Exd Phone No.: 201-394-1548 Bldg.Permit* S C-� Q, 8 email:Donboyle006C&mac.com Tax Map District: 1000 Section: Block: Lot: BRIEF DESCRIPTION OF WORK, INCLUDE SQUARE FOOTAGE(Please Print Clearly): Installation of EV Charger unit and 300A service upgrade Square Footage: Circle All That Apply: Is job ready for inspection?: ❑ YES❑NO R Rough In Final Do you need a Temp Certificate?: RYES 0 NO Issued On Temp Information: (All information required) Service Size 1 PhE]3 Ph Size:3OO A #Meters Old Meter# N/A Wums New ServiceOFire ReconnectOFlood ReconnectOService Reconnect EZU'nderground 00verhead #Underground Laterals n 1 n2 H Frame El Pole Work done on Service? Y N Additional Information: PAYMENT DUE WITH APPLICATION 2- CV �r - - - J-_.. -..ram• .,y,�4^ � F�' , L, `s, .";;}.{iit.,-,`ia' .t3' •.,.,,"" ;y:�^i'7�::; :,, ... ,Ii >r. I,t i - r a ,f-.,�• - t 1.V _ N l Ij .71 Y— J', Z Ev NiVINI Elk �� ?� - ,� _ `a• ttoA �'r 1 A0yfV� j�s� b .a,:: -,:,'7„�,, ,f�:'.: ':fic,.�:y•. a*;,=1� -:r:-. •' - r1,;J a6p _":y'.,•`.i. i ,. I`• st .:fit .� .r+ 'ti;l• —. �Esl' 3$°c'.., ,,. ,t�.'� "'9p7T6CS,ROAQ-.+ 'r �,"� i't'1. ..5 t'C.?rML`...-._ ..,..:._l:1GHS• .�'tjylp7':i:li.F. Or' r'4/r,ei` h+.'• 'n z Fri r+ �z �.ii'i�i ri+h •,f, I n.-w"a,Yr-J ,:�..:_ _ _- �'._ - - .. • �� `"4 �.1': `SUffOIk:Gounty,,Dept;:pf. -_Labbr„Licensing:,B.:ConsumerAffiiis. MASTER'ELECTRIGAC LICENSE DOIUINIQ,CHIZZONITI' Business:Naive ? -ABSOLUTE;EL CTRICAL Tafee l du)v.that;the': C6NtkACTINGA DESIGN;LLC-:'-'` f bearei is duly'licensed:"' ` j by the County of suffolk.•. .r'License Number'ME 6278A = -'Issued; '0fl21J2020 Gomri�jssioner.' Expires' 01%01t2026'. .. N Y S ' F New York State Insurance Fund PO Box 66699,Albany,NY 12206 nysif.com CERTIFICATE OF WORKERS'COMPENSATION INSURANCE �. .M AA A A A A 461609385 C QUICK INSURANCE AGENCY INC 13 W.MAIN ST STE 4 Q .,. WASHINGTONVILLE NY 10992-1444 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER ABSOLUTE ELECTRICAL CONTRACTING AND TOWN OF SOUTHOLD DESIGN NY,CORP. 53095 ROUTE 25 27 CAIN DR PO BOX 1179 PLAINVIEW NY 11803 SOUTHOLD NY 11971 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE H2582 795-7 875551 07/15/2023 TO 07/15/2024 11/13/2023 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2582795-7, COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORKERS' COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE STATE OF NEW YORK, EXCEPT AS INDICATED BELOW, AND, WITH ESPECT TO OPERATIONS OUTSIDE OF NEW YORK, TO THE POLICYHOLDER'S REGULAR NEW YORK STATE EMPLOYES ONLY. IF YOU WISH TO RECEIVE NOTIFICATIONS REGARDING SAID POLICY,INCLUDING ANY NOTIFICATION OF CANCELLATIONS, OR TO VALIDATE THIS CERTIFICATE,VISIT OUR WEBSITE AT H7TPS:IIWWW.NYSIF.COMICERTICE TVAL.ASP.THE NEW YORK STATE INSURANCE FUND IS NOT LIABLE IN THE EVENT OF FAILURE TO GIVE SUCH Na nFICAnONS. THIS POLICY DOES NOT COVER CLAIMS OR SUITS THAT ARISE FROM BODILY INJURY SUFFERED BY THE OFFICERS OF THE INSURED CORPORATION. PRESIDENT JESSE SMELSON ABSOLUTE ELECTRICAL CONTRACTING AND DESIGNS INC-A ONE PERSON CORP THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. BY CAUSING THIS CERTIFICATE TO BE ISSUED TO THE CERTIFICATE HOLDER, THE POLICYHOLDER UNDERTAKES TO PROVIDE THE CERTIFICATE HOLDER 30 CALENDAR DAYS' NOTICE OF ANY CANCELLATION OF THE POLICY. NEW YORK AT S47. NCE FUND DIRECTOR,INSL RANCE FUND UNDERWRITING VALIDATION NUMBER:413539955 U-26.3 ACo CERTIFICATE OF LIABILITY INSURANCE DATE IYYY1� 1111312 73@023 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLYAND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELYAMEND,EXTEND OR ALTER THE COVERAGE AFFORDEM BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSUR R(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT- If the certificate holder is an ADDITIONAL INSURED,the poiicy(les)must have ADDITIONAL INSURED pi ovisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement Astatement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Philip O'Brien NAME: O'Brien Quick Agency (A c.No E. : (631)474-7070 aC No 402 Main Street Aft-MAILDDRE : PhilipO@cquickinsurance.com INSURER(S)AFFORDING COVER NGE NAIC0 Port Jefferson NY 11777 INSURERA• AmTrust Financial Services,Inc. INSURED INSURER B- Utica MUtUal 25976 Absolute Electrical Contracting And Design LLC INSURER C: ACE Property and Casualty Insurai ice Company 20699 27 Cain Drive NYSIF INSURER D INSURER E- Planview NY 11803 INSURER F: COVERAGES CERTIFICATE NUMBER: CL2351005381 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR I HE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION'OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO kLLTHE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR DUL POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MMIDDIYYYY MM1DD LIMITS X COMMERCIAL GENERALLIABILITY EACH OCCU RRENCE S 1,000,000 CLAIMS-MADE �OCCUR PREMISES a occurrence S 100,000 X BLANKETAI MED EXP( y one person) S 5,000 A Y Y WPPIS63530 05109/2023 05/09/2024 PERSONALZ ADVINJURY Is 1,000,000 GEN'LAGGREGATE LIMITAPPLIES PER: GENERALA GREGATE S 2,000,000 POLICY❑X JECTT LOC PRODUCTS COMPIOPAGG S 2,000,000 OTHER: Employee enefits $ AUTOMOBILE LIABILITY COMBINED INGLE LIMIT $ 1,000,000 Ea accident ANYAUTO BODILY INJU 1Y(Per person) $ B OWNED SCHEDULED Y Y 6518564 0211212023 02/12/2024 BODILY INJU 1Y(Per accident) S AUTOS ONLY 25AUTOS Ix HIRED �/ NON-OWNED PROPERTY AMAGE $ AUTOS ONLY X AUTOS ONLY Perarsident Medical p ents S 5,000 X UMBRELLA LIAR OCCUR 3.000,000 EACH OCCU RENCE $ C EXCESS LIAB HCLAIMS-MADE. Y Y CUV-EXL-0026162-02 06/25/2023 06/2512024 AGGREGATE $ 3,000,000 DIED I X1 RETENTION S 10,000 WORKERS COMPENSATION X PER ERH AND EMPLOYERS'LIABILITY ANY PROPRIETORIPARTNERIEXECUTIVE YIN EL EACH AC IDENT $ 500,000 D OFFICERIMEMBEREXCLUDED? NIA Y H25827957 07/15/2023 07/15/2024 (Mandatory in NH) 500,000 If yes,describe under E.L DISEASE-EA EMPLOYEE $ DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached B more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED PO ICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Town of Southold ACCORDANCE WITH THE POLICY PROVISION 3. 53095 Route 25 PO Box 1179 AUTHORIZED REPRESENTATIVE Southold NY 11971 � � - ©1980-2015fACCOORR-DECO RPORATION.All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks ofACORD rw workers CERTIFICATE OF INSURANCE COVERAGE T :Canipen$at(pn .B DISABILITY DISABILITY AND PAID FAMILY LEAVE BENEFITS LA PART 1.To be completed by Disability and Paid Family leave Benefits Carrier or Licensed Insurance Agent of that Carrier Is.Legal Name&Address of insured(use street address only) 1 b.Business Telephone Number of Insure ABSOLUTE ELECTRICAL CONTRACTING&DESIGNS,LLC 27 CAiN DRIVE PLAINVIEW,NY 11803 la Federal Employer Identification Numbi ir of insured or Social Security Number Work Location of Insured(only mqulredif coverage isspedficaAyrimitedto 461609385 certain locations in New York State,i.e.,Wrap-Up Policy) 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate ShelterPoInt Life Insurance Con pony Town of Southold 3b.Policy Number of Entity Listed In Box''!a" 53095 Route 25 DBL676825 PO Bar 1179 Southold,NY 11971 3c.Policy effective period 01/01/2024 to 12/31/2024 4. Policy provides the following benefits: ® A Both disability and paid family leave benefits. B.Disability benefits only. C.Paid family leave benefits only. 5. Policycovers: © A All of the employer's employees eligible under the NYS Disability and Paid Family Leave Benefits Law, B.Only the following class or classes of employer's employees: Under penalty of perjury,1 certify that I am an authorized representative or licensed agent of the insurance carrier refer need above and that the named insured has NYS Disability and/or Paid Family Leave Benefits insurance coverage as described above. Date Signed 01/08/2024 By �G (Signature of Insurance carrier's authorized representative orWSUcerssedI ranee Agent of that Insurance carrier) Telephone Number 516-829-8100 Name and Titie Richard White Chief Executive fficer IMPORTANT: If Boxes 4A and 5A are checked,and this form Is signed by the insurance carrier's authorized representative or NYS Licensed Insurance Agent of that carrier,this certificate is COMPLETE.Mail it directly to the certificate holder. If Box 413,4C or 513 is checked,this certificate is NOT COMPLETE for purposes of Sects on 220,Subd.8 of the NYS Disability and Paid Family Leave Benefits Law.It must be mailed for completion to the WorkersCompensation Board,Plans Acceptance Unit,PO Box 5200,Binghamton,NY 13902-5200. PART 2.To be completed by the NYS Workers'Compensation Board(only if Box 4C or 5a of Part 1,has been checked) State of New York Workers' Compensation Board According to information maintained by the NYS Workers'Compensation Board,the above-named emp!a jer has complied with the NYS Disability and Paid Family Leave Benefits Law with respect to all of his/her employees. Date Signed By (Signature of Authorized NYS workers'Compensation Quard Employee) Telephone Number Name and Title Please Note:Only insurance carriers licensed to write NYS disability and paid family leave benefits Insurance policies qnd NYS licensed insurance agents of those insurance carriers are authorized to Issue Form DB-120.1.insurance brokers are NOT authorized tc issue this form. DB420.1(1047) III IIPiE�i-1o2i0�01wiii(10iai17)ii�ll�l 9 f R r /00, APPROVED AS NOTED lm B.P# 3 FEE 3 1116 BY- NOTIFY BUILDING DEPARTMENT AT 631765-1802 8AM TO 4PM FOR THE FOLLOWING INSPECTIONS: 1. FOUNDATION-TWO REQUIRED FOR POURED CONCRETE 2. ROUGH-FRAMING&PLUMBING 3. INSULATION 4, FINAL-CONSTRUCTION MUST r D a d PA/A I'M (t00 BE COMPLETE FOR C.O. l C ALL CONSTRUCTION SHALL MEET THE ' REQUIREMENTS OFTHE CODES OF NEW YORK STATE. NOT RESPONSIBLE FOR L l 1 V n DESIGN OR CONSTRUCTON ERRORS COMPLY WITH ALL CODES OF NEW YORK STATE &TOWN CODES AS REQUIRED AND CONDITIONS OF SOUTHOLD TOW BA SOUTHOLD T PLANNING BOARD SOUTHOLD OWN TRUSTEES N.Y.S.D SO OLD HPC SC OCCUFAN Y OR USE IS UNLAWFUL WITHOUT CERTIFICA- OF OCCUPANCY ELECTRICAL INSPECTION REOUIRED A A • t r &WARNING:RISK OF FIRE OR ELECTRICAL'SHOCK.Carefully read and follow all of the instructions and precautions in this User Manual and the accompanying Safety Manual.The eleetrical system used with this charger must be inspected by qualified electrician prior to use to ensure:all wiring,circuit breakers and outlets are appropriately sized and in good working condition,and comply with applicable electrical codes.If you have any uncertainty relating to the installation of this device,contact a'qualified electrician before proceeding. ®AVERTISSEMENT:RISQUE D'INCENDIE OU DE DECHARGE LECTRIQUE.Lisez attentivement et suivez touter les Instructions et prbcautions de ce manuel d'utilisation et du manuel de securitg qui I'accompagne.Le syst6me electrique utilisd avec ce chargeur doit etre inspedd par un dlectricien qualifid avant utilisation ofin de s'assurer quo tons Ids' - cables,disloncteurs et prises sont de faille appropriae et en bon Mat de fonctionnement,et qu'ils sont conformer aux codes€lectriques applicables.En cas d'incertitude concemant' ('installation de cet appareil,contactez un alectricien qualifig avant de procdder. &AADVERTENCIA:RIESGO DE INCENDIO O DESCARGA ELtCiRICA.Lea atentamente y sigo todas las instrucciones y precauciones de este manual del usuario y del manual de seguridad que to acompana.El sistema electrcco utilizado con este cargador debe ser inspeccionado par un electricista calificado antes de su use pare asegurarse de que todo el cableado,los disyuntores y las tomas de corriente tienen el tomano adecuado y estan en buenas condiciones de funcionamiento,y cumplen con los cbdigos elactricos oplicables.SI tiene alguno duda relacionada con la instolocidn de este dispositivo,comunfquese con un electricista calificado antes de continuar. I ACCESSORIES CONTENTS 1. IMPORTANT SAFETY INSTRUCTION 3 2. GENERAL 3 2.1 STANDARD STATION FEATURES 4 2.2 CONNECTED FEATURES 4 2.3 MOBILE APP 4 2.4 INCLUDED IN THE BOX ! 5 2.5 INCLUDED IN THE ACCESSORY BOX 5 2.6 EQUIPMENT OVERVIEW 5 3. INSTALLATION INSTRUCTIONS 6 3.1 WALL-MOUNTING INSTRUCTIONS 7 3.1.1 MOUNTING THE GM ULTIUM EV CHARGING STATION 7 3.1.2 MOUNTING THE CABLE WALL MOUNT .8 3.2 HARDWIRE INSTALLATION 9 i 4. INDICATOR OVERVIEW . 12 5. OPERATING INSTRUCTIONS 13 6. MAINTENANCE AND STORAGE INSTRUCTIONS 17 i 6.1 DISPOSAL 17 7.TROUBLESHOOTING 18 7.1 SOFTWARE 18 7.2 MOBILE APP 18 7.3 MANUAL RESETTABLE ERROR 19 7.4 HAZARDOUS ERROR 20 S. TECHNICAL DATA 21 9. OVERCURRENT AND SHORT-CIRCUIT PROTECTION1 21 10. BLUETOOTH® 22 11. LIMITED WARRANTY 22 12. CIRCUMSTANCES THAT WILL VOID THE LIMITED WARRANTY 22 13.ADDITIONAL INFORMATION 22 14. COMPLIANCE 23 15. FCC STATEMENT 23 16. NATIONAL USAGE RESTRICTIONS 23 17. SUPPORT 23 TO BE COMPLETED BY INSTALLATION ELECTRICIAN FOR CUSTOMER REFERENCE I i BLUETOOTH PAIRING CODE: CIRCUIT BREAKER SIZE: I RECOMMENDED CURRENT SETTING: PART No. SHEET R 02AUG22 i ALL IN FORMATION mT NABOVE Date Revision Auth DR Title GM Ultium EV Charging Station BORDER TO BE PRINTED E%ACTLY A.sHowNONes■1LWHITEte 02AUG22 First Rel SAR, AH 'User Manual POUND NON•BOND RECYCLABLE PAPER.PRINroN ESSTDE PART No. SHEET , PAPER.EXCLUDING TETAPLATES. ID BE UNITED IN ACCORDANCE Wf7I/ - GMCCASPECIFICATONS. 7 Arm- 0ma= .Cs-CESS0RIES NOTE: For the latest version of the manual visit.GM:com.- ;. a - 1. I M PD RTANT SAF:ETY� I'IV'STR U;CTI-O N- &'WARNING: Use thq.q_ M' sUltium-'EV Charging Station according-to GM and.co mpany'instructions as detailed in the_; supplied user manuals,to avoid RISKS OF FIRE;ELECTRIC SHOCK,or injury"to persons. &WARNING: Read and understand'the supplied 'GM'Ultium'EV Charging Station Safety Manual'. If you are uncertain about any aspect of the installation, consult a qualifie8F electrician. &WARNING:%Read and understand the fitted safety_Jnfo�mation label before.attempting installation or operation:o66. GM Ultium EV Charging Station. DO NOT attempt to remove the safety information label which can be located in the position shown below. r 1 ' 1 . 2. GENERAL • This GM Ultium EV Charging Station is designed for charging of Electrical Vehicles (EVs) only. See the vehicle owner's manual for more information. • Remember-to save the Bluetooth® pairing code-.this;is`regqLired to connect the.unit to the mobile app.The last six numbers of the Bluetootfi®:pairing code can be foundsbiri-the heatsink of the GM Ultium EV Chargih' 'Station. OM EV)OD000( PART No. SHEET R,02AUG22 BO I FOPPAAIgo N�N�� Date - Revision � - Auth DR Title GM Ultium EV Charging Station A9sHEOWR NON86x11 WHITE ID 02AUG22 First Rel SAR AH POUND NOt180ND RECYCLABLE - User-Me'rival PAPER.PRINTON BOTHSIDES ExCLUD NG TEMPLATES.TO BE' PART No. SHEET '� "UNITED IN ACCORDANCE WITH GMCCA SPECIFICATIONS. AIC-CES.SO-RI.ES I . 2.1 STANDARD STATION FEATURES Max Charging Power Plug in-9.bk Hardwired- 11.5kW Charge Cable Length '25:ft. (7.5m) Plug NEMA 14-50 or 12QFlerdwire g Max:Operating:Amps' . 48,amp I - BreakerAmps 60 amp [Energy Star..Certified; ' • Yes . . Static Load Balancing 2.2 CONNECTED FEATURES Ethernet No (.WiFi Enabled Yes Mobile App ( 'enufec-turerJ Yes t"Bluetoo#h® Yes (approx.33ft(1.0rn)"range) Branding Single Brand I OCPP 1.6 Yes =ver-ThM, Firmware Update Yes Service support_ _ u__r �; _______ _ _ °Yes - ; 2.3 MOBILE APP GM have a range of mobile,applications that can be used with the,GM Ultium EV Charging Station,which include: I (UIlialll imail myBuick myCadillac myChevrolet myGMC Ultium Charge 360 Use the appropriate brand app associated to your GM vehicle. Incase you do not have'a GM vehicle but use a(GM Ultium EV Charging Station, use the Ultium Charge 360 app. I NOTE:The GM app will be referred to as the 'My Brand App'throughout this user documentation. I i f - PART No. SHEET R-A2A4U022 ALLINFO,FbWT10NVA7HINABOVE Date'' Revision Auth DR Title - GM.Ultium EV Charging Station BOR ER O BEE PRINfEO EXACTLY ' AS SI♦OWN ONES x17 WHITE IB 02AUG22 First Re] SAR POUND NON•BONO RECYCLABLE User Manual PAPER.PRINTONBOTHSIDEM EXCLUDING PIATES.TO - PART No. SHEET UNITED IN ACCORDANCE WITH _ 4 GMCCA SPECIFICATIONS. A°C'CESSO RI ES 2.4 INCLUDED KTHE''B4OX Q 1. GM-Ultium'EV'Charging Station 2.5 INCLUDED;IN-THE"ACCESSORY-BOX 2. Cable Wall Mount © © ' 3. User Manual/Safety Manual/Drilling template 4. Multi-Bit Screwdriver 5. 2 Screwdriver.Bits 6. 8 Screws 7. Blind Plug f: I i s 2.6 EQUIPMENT OVERVIEW r. 0 1. GM Ultium EV Charging Station with indicator t panel 0 [1 dMa 2. NEMA 14-50 Plug 3. EV Type-1 Connector 4. Charging Station Wall Mount f i 0 PART No. SHEET �R"02AUG22 DB RIDERT�OSnEPONRIN""rEnNABOcn Date Revision - Auth DR Title GM Ultium EV,Charging Station AssHowN-oNes:»wee 02AUG22 First Rel SAR AH POUND NON-SONDRECYCLABLE Uses Manual PAPER.PRJ ON BOTH SIDE - ExCLUDINOTEMPLATES:ToBW PART No. SHEET - 5 UNRED IN ACCOROANCE MM - yF GMCCASPECIFICATIONS. t i ' :'Ai'.C:�C E S.S D R I E S I :® i 3. INSTALLATION INSTRUCTION'S IMPORTANT INFORMATION: • &WARNING:When installing the GM Ultium EV Charging Station,keep the location of the vehicles charging port in mind so that the charging cable can reach. Mount the cable jwall mount near the charging port for ease of use. • &CAUTIOM-She,GMUltium'EV.Charging Station locationimust be safe.and-adequate,.to avoid any hazards.. • &CAUTION: This device shall be mounted at a sufficient height.:from'grbund such that the height of the storage means for the coupling device is located between 24 inches (600rom,) and 4 feet (1.2m) from ground. NOTE:for indoor use,'24 inches (600mm)can be changed)to 18 inches (460mm):" - • &CAUTION:The installation of the GM Ultium EV Charging Station require s%a,NEM,A'1'A-50 outlet with ground at the TOP position. If not available, it must be installed by a certified electrician. • &CAUTION: Hardwire installation must be performed by a certified electrician ONLY. • &CAUTION: If the GM Ultium EV Charging Station is damaged during installation,'stop th,6 installation, and contact the company(refer to SUPPORT section or further information). • . &CAUTION: Make sure the installation of the unit obeys any mandatory local rules,permits and laws. • &CAUTION: Make sure to,have.approval ftom,the property owner,or condo=associatio646r,the;installation: • &CAUTION: Make sure stainless-steel fasteners are used tor°all mounting installations: } I I I I , i PART No. SHEET R,02AUG22 -ALL INrDrOA ONVVrtHIN ABovE Date I,. Revision Auth DR _ BORDER'TOB RI D cnY Title GM Ultium EV Charging Station As sm-6N c as x ll vJHITE 16 02AUG22 First Rel SAR User Manual 'POUND NON.BOND ltEGYCLPELE AH P I ON BOTH SIDES E c�cLibll'ia r�ExtPUTES.,To BE PART No. SHEET UNITED IN ACCORDANCE WITH GMCCASPECIFICATION& - ® 'A.VCESS0R-IES 3.1 WALL "MOUNTIN INSTRUCTIO:NS The included screws are for convenience and can only be used on wooden surfaces.They can also be used on''concrete if used with concrete-wall anchors. IMPORTANT INFORMATION: &CAUTION:Make sure a surface that is appropriate for the weight of the GM Ultium EV Charging Station is chosen and that the correct screws are used for the intended surface and that the unit is safely rriounted on the wall before using the unit. If there is uncertainty of which surface is appropriate or which screws are suitable for the application, contact a specialist to seek advice. This device shall be mounted at a sufficient height from ground such that the height of the storage means for the coupling device is located between 24 inches (600mm) and :.A feet'•(1..2m) from ground. NOTE:for indoor use, 24 inches (600mm) can be changed to 18 inches (460mm). Installing a padlock is recommend to prevent theft. Padlock not included. 3.1.1 MOUNTING THE GM ULTIUM EV,CHARGING STATION 1. Unscrew the four screws including the security nut 2. Mount the charging station wall mount to the (highlighted) to access the charging station wall intended surface, using the screws provided (where mount, keep the screws (see step 3). applicable). Note:a.drilling template is provided to assist installation. i 0 0 0 � O PART No, SHEET R 02AUG22 BBOROE�RR TO BE PR M" `T%L Date' Revision Revision Auth DR Title GM Ultium EV-Charging.Station AS SMOWNON 0.5x11 WHITE 16 O2AUG22 First Rel SAR - PppOppUEEND NpbN-SONDRECYCLABLE •,User Maniiai F�LCLUDING TQPLLAATTESS.TO Bf: T UNREDINACCORDANCE WITH PART No. SHEET 7 GMCCA SPEGPICATIONS. - • �.�A��C C ®S R_ICE 5 I 3. Reattach- the GM Ultium EV Charging,--Statiorr:on the wall mount using the previously r`emoved'screwa ,. From Step 1. If a padlock has been purchased, secure the unit by locking the padlock on the security nut. I I I I I 3°1.2 MOUNTING THE CAGLEVALL MOUNT 1. Unscrew the two screws at the bottom to access the 2. Mount the mounting bracket to the intended surface, mounting plate, keep the screws. using the screws provided (where applicable). Note:a drilling template is provided to assist installation: li 3. Reattach the cable wall mount on the mounting bracket using the previously removed screws (see step 1). i I 11 I PART No. SHEET ,R•02AUG22 •AIL INPOfdtATIONWfTHM ABOVE - Date . Revision Auth . DR-Title GM Ultiui'n EV..•Charging Stati BORDER TOO BE PWNTFD ExACiIY AsslwwNONBs:nwrBrE,e 02AUG22 First Rel SAR AH ..User Mani PpOUND•NON-BOND n°I F . EXCIWUDM6TE I TE&Toed PART No. •SHEET ' umnEDINACCORDANCEWFM GMCCA SPECIFICATIONS. I � QWA= :A`.0ZESS0R•IESAM ,; d 3.2-',`• ' HARD;WIR•E; INSTALLATION &WAkNING:IMPORTANT-Hardwireinstallation can be performed by certified,electricians ONLY., &CAUTION: Use 6 AW6,;75°C copper wire'or higher specification for field wiring,installation. A hardwire installation.requires',remgv!ng:t6.6,`N,MA 14-50 plug,in order to permanently wire the OM_Ultium EV Charging Station to the main;incoming._sup ply.; The hardwire installion of-,the GM'Ultium_EV Charging Station can be reversed and the NEMA 14-50 plug refitted. 1. Remove the two screws locdted at the end'of'the 2. Remove the two service lid screws (keep the screws y front cover(keep the screws for reassembly) for reassembly),-Remove.the service lid using �• Remove the front cover. . _ pliers and pull on the tabs as shown. I !�i •:+' !`,a S" ;ice ;: V M1 k3. Loosen the highlighted cables from the terminals. 4. Remove the four screws and washers that•secure the cable clamp—Remove the cable clamp (keep screws,washers and-cable clamp'for reassembly). •l _ a t: NOTE:Components may have been removed for image clarity. NOTE:Components may have been removed for image clarity. i ill } ? - PART No. SHEET R 02AUG22 e �eEawr�E cnY Date. Revision Auth DR Title GM Ultiurn EV Charging,Station 4 AssQio mONa xnwru to 02AUG22 First Rel SAR l Pburro NON-BOND-RECYCLABLE User IV16rllJal PAPE(t PRIN 0NSOTHSIDE3 t ExcLUDNO TEMPLATES.TO,9E' PART No. SHEET .4 UNITED IN ACCORDANCE WITH -- - 91 t GMCCA SPECIFICATIONS. I -,A'C-'CES'S0RIES 5. Loosen the nut for the cable gland pull out the &-.Change position.of;the switch-,(the`switch is high- cable. lighted in'the irnage) to the'`HARDWIRE' position. A small screwdriver may be required to assist. v ;010affea e I _x ;.�.; NOTE:Components may have been removed-for image clarity. I 7. Remove the nut and pull out the cable gland. 8. Insert the blind plug-included with the accessory kit into the opening for the:ca6le gland from the bot- tom. Secure it;with the nuiffrom Step 1) and tighten it to 131 ft%Ibs(1;3 Nm). Refit the cable clamp assembly'(from Step 4). °"uC7000� j I - e I � . NOTE:Components may have been removed for image clarity. NOTE:Components may have been removed for image clarity. 9. Unscrew the,blind'plug provided iti the"heatsink. 10. Make suVe a suitable 1"water.tig%hi'aconduit com- pliant to type 4kand an•_adapter-is`vsed to fit the 1.3 in (33,7 mm)aperture shown Push the new (round)cable through;the.aperture. I M(Ii�flM(�ffU� - � I- ® - el m � O e � � Make sure the o adapter does not A - protrude to the rear of the unit that � it will interfere with wall mounting. NOTE:Components may have been removed for image clarity. PART No. SHEET R'Q2AUG22 ALL INFOwAATONNn7HINABOVE Date Revision i Auth DR role - GM Ultium EV Charging Station BOROER TO B PRINTED E%AC'TL.Y AS SHOWN ON S.s■I I WIUTE Is 02AUG22 First Rel SAR AH POUND NON•SOND RETCYCLABgL,E User Manual CL UIN�G TMEM�PLA�S.To BS PART No. SHEET UNITED IN ACCORDANCE WITH - 1 OMCCA SPECIFICATIONS. � =Mr- -kC'CESS0RIES 1,1:-Iristall-the,cablesafrom the�.direction;shown in the :;12: Reattach the'service lid with,its twoac�ews and terminals=and tighten tfie,.rrrtindl screws to 2.5 ft/ tighten them to 0.7 ft/Ib's(1 Nm): ` Ibs (3.5 1Nm).= NOTE:Components may have been removed for image clarity. 13. Re-attach the Front cover with its two screws and tighten them to 0.7.ft/Ibs (1 Nm).The hardwire installation is 'no w firiislied. I � � i I I _ f I : v I 1 ' 1 PART No. SHEET FF :R02AUG22 AUI PQPR��gq7T�IorltivmnN vE Date Revision Auth DR BOWER TOBEPRINTEO ESinocnr Tltle GM Ultiu_m EV Charging Station I AssNowNONBs:„wwrE,e 02AUG22 First Rel SAR User Manual POUND NON-BOND RECYCLABLE PAPER.PRINTONBOTHSIOES PART No. SHEET EXCIUOINO TEMPLATES,TO 8N' 1 GMCCA TED IN ANCE E WITH 1 1 qa S i 4."INDICATOR"'OVERVIEW ::, '.,}?ONE3 ZONE 2 The EV Charge Station is equipped with an indicator panel located on the from of the.unit. om0 The indicator panel displays charge status and errors. ^. ZONE FUNCTION •N INDICATION ACTION POWER Power is on ZONE ZONE 1 2:: FADING FADING No--action device is functional' Charge cable correctly " connected ZONE 2:SOLID LIGHT No action required;.deviceiis'functional I Charging in progress ZONE l: FLASHING No action required,device is functional ZONE 2:SOLID LIGHT CHARGING Vehicle fully charged charge cable can be Charging complete ZONE 1:SOLID LIGHT removed and stored ZONE 2:SOLID LIGHT For more inform6tiori;,refer to: OPERATING INSTRUCTIONS STEP 10 Charging manually paused via the Charging paused ZONE 2: FLASHING Manufacturer App Refer to App for further information or to resume charging I A software update is in progress.For more UPDATE Software update ALL ZONES: FLASHING information,refer-to; . ! TROUBLESHOOTING—SOFTWARE . I Hazardous error ZONE 3:SOLID LIGHT For more information,refer to: TROUBLESHOOTING ! ERRORS I Manually resettable error ZONE 3:FLASHING For more information,refer to: TROUBLESHOOTING R 2AUG22 PART No. SHEET 0 'ALL INr-0RMATigrNTHINAEovE• Date. Revision Auth DR Title GM Ultiurll EV Char9 �ir.1 -Stati( BORDERTOBEPWNTEDE)(ACTLY . ASSHOWNON0.5:11WHRE16 02AUG22 First SAR AH User ManU POUND'NON-BOND RECYCLABLE - PgpER PRINTON BOTHSIDES E%CWDINO TEMPLATE.To BE! I PART No. SHEET UNITED IN ACCORDANCE WITH OMCCA SPECIACATONS. I 9 A.C`CESS0RIES ._ 5: O�PER••ATIN,13:"-INSTR:UCTIO:NS' ; 1- &CAUTION: Where possible to do so, switch off the supply power at the circuit breaker to the GM Ultium EV Charging Station before connecting the NEMA 14-50 plug. Connect the power cable to the outlet with the NEMA 14-50 plug restore the,power supply to the GM Ultium EV Charging Station from the circuit breaker. ' r When the GM Ultium EV Charging Station is connected to the outlet,and powered'on,ZONES 1 &2 will fade in and out. I 2. Bluetooth®connection: is e Android - Swipe down from the top of the screen Press "Bluetooth®"to activate i • iOS - Go to"Settings" "Bluetooth®" toggle to activate Other operating systems- Refer to the smart mobile device manual to correct) establish the Bluetooth@ connection P 9 Y Y 3. Install the GM My Brand App: • Android - On the smart mobile device go to "Play Store" search for"My Brand"-+"Install" • iOS - On the smart mobile device go to"App store" -i search for"My Brand" "Get" "Install".-" • Other operating systems - Refer to the smart mobile device manual to correctly select the App store and install the My Brand App 4. Open the GM My Brand App and follow the instructions to register an account and configure settings. I I 5. To pair the smart mobile device,the GM Ultium EV Charging Station must not be connected to a vehicle. The pairing mode is always active. When paired,the smart mobile device can be connected to the GM Ultium EV Charging Station during any point of use. 4 . S PART No. SHEET R 02AUG22 1 ALLINFO%AnoN rmmrneovE Date Revision Auth DR Tttie GM Ultium EV Charging,Station BORDER•TO BE PRI D EXACTLY j AS SHOWN ON S.6,c 11 WHITE 78 02AUG22 First Rel SAR AH POUND NON"BONDRECYCLABLE User Manual PppER,PRINT ON BOTH SIDES, EXCLUOINGTEMPIATES To BE PART No. SHEET 13 •UNM IN ACCORDANCE WfTH GMCCA SPECIRCAMONS. CNN= 1MV 61C E S'S 0 1111 E S 6 When connecting a smart mobile device to the, EVChaildihg Station-,enter,th6_,Bli!dt66th@.pairidg--cod . A The last six numbers of the Bluetooth(D pairirig-`cio"&dre f6un'do'n"thelhdaisihk for tWe-' -:Uifiuim' -'-'EV.Chcrgi'ng Station. After pairing,all features of GM My Brand App can be used. .................................... �j rq 7. To charge, refer to the vehicle owner's manual to find the charging outlet location and how to correctly connect the GM Ultiurn EV Charging Station to the vehicle. I Before connecting the GM Ultiurn EV Charging Station to the vehicle, make sure the electric p6W6f/v6lta_ge is suitable, according to the vehicle owner's manual. _ � PART No. SHEET R-02AUG22 ALL -Charging Stati Date Revision Auth DR Title GM Ulti,unn EV OM'nEOPNJ=N&KOVN BORDER AS kOWNONUX'1'1VVI4M16 02AUG22 First Rel SAR AH User Man, SH POUND NON-BOND RECYCLABLE SHEET UN N WO E1*TH EXCLUDING DE EXCLUDING tOOTETSHATIO ElSe PART No. OMM ISF�SPECIFIC ATIONS. :;AttESS,0R,1ES 8. . FULLY UNCOILTHE CHARGING CABL&BEFORE CONNECTING: When the charging plug is connected to the vehicle charging outlet correctly, ZONE 2 on the indicator panel will show a constant light.The GM Ultium EV Charging Station will be waiting for a smait'mobile-device to authorize a charging session or.the pre-programmed charging schedule to start. oltlama � ' 7 It�ll ,I 9. During charging: • ZONE 1 Flashing • ZONE 2 Constant light When the charge is complete -i • ZONE 1 Constant light' • ZONE 2 Constant light a i 1 i ,f 1 i I 10. When the vehicle is fully charged: • Unlock the charging plug from the vehicle charging outlet as per the vehicle owner's manual • Loosely wrap the charging cable on the wall mount so that the cable doesn't come into contact with the floor • Put the charging plug back into the holster Y 6 � PART No. SHEET R'02AUG22 BOLIiDERT06E PfiINfE�DNE%ACTLY, Date.' Revision Auth DR Title GM Ultium EV Charging Station AS SHOWN ONS.SZHYJHITEIB 02AUG22 First Rel SAR AHUser Manual POUND NOWSOND RECYCLABLE PAPER.PRIM ON BOTH SIDES ExcLUDINC TEMPULTEs.ro e� - . PART No. SHEET 15 i UNITEDINACCORDANCEN9TH + OMCCASPECIFlCATIONS. ;AKftO ® At'C'ESS0R1ES ' ` £' i 11. After disconnecting the GM Ultium EV Charging Sta#ion;•lock'tle'charging outlet as Pei-the vehicle owner's manual. I =�etilt�ll�,� • ZONE 2 flashing inijicates that the charging session was manually paused via the GM My Brand App. Refer to the ;z GM My Brand App for further information or to resume charging. ¢moue � . .L-;- - I I I I _ I PART No. SHEET ^; 02AUG22 ALLINFORMATIONWfTHINABOVE Date , Revision 'Auth DR Title GM Ultium EV'Charging Statio ggpppp�ILER BEPRINTEDEXACTLY 02AUG22 First Rel TSAR User N1c1nU' AS SHOWN oN 8.6 x 11 WHffE 1B POUND ON-BONDRE&CIASLE ! PAPER PRINTONBOTHSIDESE PART No. SHEET •;-1 -EXCLUDING TEMPLA7FS:TO B UNITED IN ACCORDANCE W GMCCA SPECffICA710NS. ITH :1 � E S S 0 R I E S B.' MAINTENANCEAND -STORAGE.-'`]NSTRUCTI'GN,S. . 0 &WARNING: DO NOT open the GM Ultium EV Charging Station;contact,.q certified-electrician.;.: 0 &WARNING:To reduce risk of ELECTRIC SHOCK,unplug GM Ultium EVCh1drg'in"g Station"fr"Offi-AC outlet b6fio�e attempting-,cleaning where-possible: 0 &CAUTION:To clean the GM Ultium EVC_harging-Sta"tio6 including the heatsink,1.use a dry cloth where'postible. ID h -rgirig,Station , not d&CAUTION: Th.e.'GM,LJItium.EV C a is Oesigqed,.to be har wired.reppatedly.9nd.uninstalled, _dq'-ingsom.aycqysed"` ' ' h vnjff.'� _' qmqge tq.t e j Ch I d i• &CAUTION:The GM Ultium EV" 6r "j'ng'Sta't'ioni*sdesighed't'obe"irfsfcille'd 'and're'm'ain' haidw'ir'epugg-e n, and not meant to be stored after each use. 0 &CAUTION:To'stord or relocate a-hardwired GM Ultium EV Charging Station contact the manufacturer customer service or a Certified Electrician., 6.1 DISPOSAL ®CAUTION:DO NOT place the product in regular trash contained SteictIV,:f6liow the loca[,re6ulatjons-regarding the disposal and recycling of product. PART No. SHEET ALL 1NrOPjAA_"ONM`DCNAB6VE = Date Revision Auth DR Title GM Ultium EV Charging Station BORD ER :%D EXACTLY AS J,f ._. 17S 16 02AUG22 First Rel SAR AH Wei MahLial POUNDNo 14-SOND RECYCLABLE MUDIKFUUJLBOTES.TOTHSID G M PART No. SHEET' 6WTEDINACCOD _GMCCA SPECIFICATIONS.W" I ,"1A'C-CES'S0R1ES 7 TROUBLE.SHOOTING 7.1 SOFTWARE,.. • Before updating the GM U.Itium EV Charging Station software, make sure there is a stable internet connection via Wi-Fi • More information regardirig'tlie latest software version can be fo nd on the manufacturer website,visit GM.COM ' • IMPORTANT NOTE:,If the.internet connection is not stable,the software update process may take longer'than expected • Software update status can be viewed on the App and by the flashing indicators shown below . I i MUM. ' I I I 7.2 MOBILE APP • IF there is a power interruption,the Mobile App will show that thl'GM Ultium EV Charging Station has stopped the charging session due to an error • If charging an EV with the GM Ultium EV Charging Station and'Jhere is a power failure,the charging session will stop When the power is restored,the charging session can continue • Power failures will not affect the Mobile App Charging Schedule • The App will display information related to errors and suggested actions When using the Mobile App, make sure Bluetooth®is activated on the smart mobile device and that it is within • Bluetooth® range of the unit I I I I I I I ., I PART No. SHEET R.02AUG22 uuNFo�+nAno NnebvE Date Revision Auth DR Title GM Ultium EV Charging.Statio sHw6io�eBA Xjj WHITE a Y 02AUG22 First Rel SAR AH User Mania, ' POUNOTN��DRRNINBOpNyDgRpECYCLABLE - - E%CLUOINGTEMPLATES.TO BE' - PART No. -SHEET 1, 'UNIM IN ACCORDANCE WITH - GMCCA SPEC7PICATION3. ? . E S S,0 R;1 E�S x _ - 7.3 - - MANU 4LLY RESETTABLE��ERROR: '.' . 1. If ZONE 3 indicates a flashing light;as shown below,it means that a resettable error has occurred. uMina 2. Remove the charging plug from the vehicle's outlet 5 Wait for the ZONE alight to stop flashing • Reconnect the charging plug to the vehiclee's outlet, 0 3. If the error still appears after a maximum of 3 attempts->check`the mobile app for overheating errors-*allow the GM Ultium EV Charging Station to cool down. 1 If the error is still:present,contact the manufacturer dealership or sales point(refer to SUPPORT section for further information). ACAUTION: DO,NOl attempt to connect the GM Ultium EV Charging Station to the vehicle. I i 1 - - PART No. SHEET qt !R`02AUG22 3 ALL INFORMAnoNwrrHlriaeovE. Date,-- Revision -- Auth DR rise GM Ultium EV Charging Station E R ER EE PN WR 9 9. rsQsl?ow�°owasx„�iNTie 02AUG22 First Rel SAR AH POUND NON-BOND RECYCLABLE tJse�Manual PAqpER PRINT ON BOTH SIDES. E%CLUDINGTEMPLATEST?PE PART No. SHEET 9 UNITED IN ACCORDANCE WITH 1 �7f GMCCA SPECIFICATIONS. I A'>C`CES40,1RIES 7.4 HAZARDOUS-ERIROR 1. If ZONE 3 indicates as shown below, it means that the unit needs servicing or replacing. i I I 2• • AWARNING:Where safe and practical to do so;Icarefully switch the GM Ultium EV;Charging Station circuit breaker at the mains supply to the'OfP position " ©WARNING: DO NOT attempt to connect the GM Ultium EV Charging Stdtio"A"f6`tfie vehicle• &WARNING: If the GM Ultium EV Charging Station is connected to a vehicle, DO NOT attempt to disconnect from the vehicle or touch any of the equipment or vehicle • .&WARNING:Contact the GM dealership or sale point(refer to SUPPORT,section or further information). • AWARRIING Notify the GM Ultium EV Charging-Station owner's and or operators. I I . i PART Ho. SHEET R�02AUG22 nulNroRMA TION�+/THINq8 Date Revision I Auth DR Title GM Ultidrh EV Charging Ste BORDER TO Be PRIWEDEOMLY 02AUG22 First Rel SAR A9 8HOWN ON 85:11 WHITE 18 User Mai POUND NON-BOND RECYCLABLE EXCLUDINGXCT''�EM�PLA�TE3 SIDE PART No. SHEET UNITED IN ACCORDANCE WITH GMCCA SPECIFICATIONS. i '.A:CrCESS0RAES B. TECHNICAL DATA Model number _3004: S Charging"method ' AC Level Vehicle connector; T (Mains tor connec ` ' NEM_A 1�4-50. I ,..,��.- _ -.,-�- •_;�'-' ,,_ - ,--;tea.=T• �:a.r � .: . � � , ( tpNuiimbe o t�h6se's 'S lifi:sinn�le- hase. � pw->= � "` "x -»:tL_.� ........v.,..�.,,�1'._...:.,,......r _.._- ;.rf b j tCharging'voltage 120/w208 V,. 120,.240 V j P Char('�in"curreiifi'" 44 48'-A' - ' w...s...a_«..g:..-r.,.n.a.u3.-_:.._,:........ .........,..,..,.;..._....n.../w:++-+,.... _ _..._,s,....-.._ .xi..a..�Y..i_.'�w'...a.a�.�..:. .. Rated:frequency,fn _ 50-60;HH Chap*in owes 9(i"ktiN V11>5:k .:.� - _ g._g`A_ �� :: .. • =_ _._,. r z;z" ZRW 'Humidity -90A, ."NK4`r dv'f':�.,.: - ...,*gin- r.�Yr,-i.,-p-�:-.'✓&;r�3 `P'""�=�'S:'�' �, "'"`&..3c�'�.e,^ ,+•'" �',@i:,_�,� ^z'.-;'; Maxi:Altifiue 1�'1483,ft J3500 m) i C_ooling Heat.sink,:nat-eal"corrvecfion' _ neF ',meter.: Yes'=*interrial :Z .°: a �'Positianing' ' _ Fixing p1afe,wall�m6'u6t _ - Enclasure,dimens ons ,fi x'9>8`x:1'7.2:'` .., _._ Hic};es:{152:4`x 249�' 43'6:9,mm Enclosure'rni terial MPlastic,'metal, i _�...�:.�.�r�, Enclosure..color.. _._. -...... :gin. ,._. �'•.'�' .. _.��.._._. .�:��-:._...._.,,�:��.:, ..�.�.._-..:�,_.,�._ Degre_e.o_f protection Watertight,-Type 4X Char e ccible len t1i' 25 ft: 7.5 rim} r, _ g (_ _t _ _.._ w _ _ .-_ 3 Mains cable'length' -1Rft. Nefiwei ht.(unitwi#h cdbles A roximately'24'Ibs 10:9k✓ i Net.weight:(holster): Approximately 7,Ibs (0;8kg). Packaging weight ... Approximately�351bs Packaging size'(LxWxH)' 30.7 x 13:8 x'7.`3:inches(780_x x'15'.4m):350.5' �8ym { User�infierface LED interface _ w ..,.,.__;^.v_-.,,•_:......�_ �.., ..._ Bluetooth@-,Viireleso ttechnology, 1Cammunic6tion-protocolQCPP 1.6 ;App support ry Smart device display;.'Manufacturer App for Android and iOS _ z A b o e(ati n ein` rat re~ 4'0 �22 F to 1.22. F -30 Cato 50 .G } and i ragerte ecature. 1 ; S. OVER URRENT° AND SH®RT-ORCUIT PROTECTION Rated.current ;'Ground fault detection In#egrated;.no additional required,_(CCID20);~ Rese# _ yz- t PART No. SHEET :..R 02AUG22 ALUNFoRIMnoNWiTNIN ABOVE Date Revision Auth DR Title GM UltiUm EV Charging Station AI�.4 SHOWNON 8S xr11�WH1TE 8 Y g ! 02AUG22 First Rel SAR AH User Manual POUND NON-BOND RECYCLABLE - PAPER. PRI�PNIATEB,TO 8� PART No. SHEET 21 UNr7ED IN ACCORDANCE WRH GMCCA SPECIFICATIONS. i i tl .XeCESSORIES t - I 10. BLUETOOTH° The Bluetooth°word mark and logos are registered trademarks owned by Bluetooth SIG, Inc.and any use of such marks by GM is under license. Other trademarks and trade names are those of their respective owner's. 11. LIMITED.WARRANTY GM issues a limited warranty fo the original'purchaser of the peoduct..This limited-warranty is not'transferable.The I warranty applies to manufacturing faults and material defects.-The.customer must return the product for inspection together with the-receipt of purchase to:the retailer.GM,will,in its sole discretion,either(i) return the product"to customer if it is not determined to be defective,or(ii)without'regard to whether or not the original product is determined to be defective, either(A) provide customer with.a new replacement product ofithe same or comparable model to customer,or(B) provide customer with-a full refund.for the product purchase price.This.wdr�anty`is void-if the GM'Ultium.EV Charging.Station (3004) has been opened,handled carelessly or repaired by anyone other than GM or its authorized representatives. THE FOREGOING WARRANTY,.RIGHTS.AND REMEDIES ARE EXCLUSIVE-,AND IN LIEU,OF ALL OTHER WARRANTIES, RIGHTS OR REMEDIES;-EXPRESS-OR-IMPLIED,WHICH MAY OTHERWISE BE AVAILABLE;ALL OTHERWARRAWIES, INCLUDING BUT NOT LIMITED TO,ANY WARRANTY OR'MERCHANTABILITY OR FITNESS FOR A_PARTICULAR PURPOSE;.ARE HEREBY EXPRESSLY DISCLAIMED, EXCLUDED AND WAIVED,BY Customer TO-THE--FULLEST EXTENT PERMITED BY LAW. UNDER NO CIRCUMSTANCES SHALL GM;QR ANY AFFILIATED PARTY'THEREOF BE LIABLE FOR ANY-INDIRECT, INCIDENTAL, PUNITIVE OR.CONSEQUENTAL-DAMAGES OF ANY KIND.` Warranty when purchasing as package(Vehicle grid GM`Ultium EV Charging- Station (3004)) When acquiring an GM Ultium EV Charging Station.(3004) bt-the moment of the vehicle,purchase, different warranty time might be applied, according to the company offers and conditions. 12. CIRCUMSTANCES'THAT WILL VOID THE LIMITED WARRANTY If the seal of the product is broken, purposely damaged,or in any way modified or altered;including cables,electronics, mechanics or other parts of the product; products that have been repaired by anyone other than GM or its authorized i representatives; products that have been subject to the use of supplies and accessories other than those approved in { writing or supplied by GM;improper use or non-compliance with installation,commissioning, operation.or maintenance j instructions (i.e. not according to the operation and installation manual); unauthorized modifications, changes or attempted repairs;vandalism, destruction through external influence and/or persons/animals;failure to observe applicable safety standards and regulations;faults caused by fire,water, snow, moisture, or other liquids-except as, specified for normal use; products where the serial number is defaced,altered or removed;any utilization of a.product that is inconsistent with either the design of the.product or the way GM intended the product to=be used;any installation and/or modifications that prevent normal service of the product;normal wear and tear and"cosmetic,damage such cis,- but not limited to, corrosion,scratches,dents, rust,stains, non-functional parts such as, but not limited to,plastics-and finishes;damage, fault,failure and/or imperfection caused by abuse, tampering, illegal use, negligence, prolonged use or operation;or faults in any.other way caused by the customer/retailer/user. 13. ADDITIONAL INFORMATION GM makes no other warranty than as*set out herein;and GM shall in no event be liable for-any indirect oir consequential damages.The faulty product shall be returned with the receipt to the retailer/place of purchase together,with a fault description. Goods returned to GM will beat GM's discretion and only valid with an approved Return Material Authorisation"(RMA) Reference Number issued by GM to the purchaser:Products sent directly to GM,without an RMA will be returned to the sender at the sender's cost.The warranty period for a product is stated in the applicable product user manual supplied with the product.The warranty is only valid if the warranty period has not expired. If the warranty claim of a faulty product is not approved by GM, the product will be returned only if the sender explicitly so requests. The customer/retailer/place of purchase will pay the freight. Faulty products will be repaired,or replaced with an exchangeable product, and returned at GM's cost. If the warranty period has expired,the product will be returned without further investigation at the cost of the customer/retailed/place of purchase. Faulty products will be scrapped PART No. SHEET R 02AUG22 I ALLINFOoRMATION WI THIN A80VE Date Revision - Auth DR Title' GM Ultium EV Charging Stati BOROEI7 TO BE PRINTED ENACTLY AS SHOWN ON 8.5 X 11 WHITE IB 02AUG22 First Rel SAR AH User Mani POUND NON-BOND RECYCLABLE PAPER PRINTON BOTH SIDE iEXCLU NO TEMPLATES.To B PART No. SHEET R UNITED IN ACCORDANCE WITH GMCCA SPECIFICATIONS. 'CESSOR'IES _ 9 by GM if deemed not repairable.GM reserves the right to vary, modify or change the terms and conditions:herein.due. ? to change(s) in availability of services,products and/or spare parts, or for the purpose of complying"with applicable' policies, rules, regulations and law,without notice. 14. COMPLIANCE • UL 2594 • UL 2231-1 t 4 • UL 2231-2 • CSA C22.2 No.280-16 - • CSA C22.2 No.281-1 • : CSA C22.2 No.281-2 15. FCC STATEMENT This device complies with part 15 of the FCC Rules.,Operation.is subject,to the following two conditions: (1;)This device may not cause harmful interference,acid (2) this device must acceptFany interference received, including interference that may cause undesired operation. NOTE:This equipment,has been tested and found to comply with the limits for a Class B digital device, pursuant to part 15 of the FCC Rules.These limits are designed to provide reasonable protection against harmful interference in a residen- tial installation.This equipment generates, uses and can radiate radio frequency ene"gy and, if notInstalled and used in accordance with the instructions, may cause harmful interfererice'to-radio communications. Howeve'r,"there is no guaran- tee that interference will-not occur in a particular installation. If this equipment does-cause-harmful interference to radio or television reception,which can be determined by turning the equipment off and on,the user is,encouraged to-try to correct the interference by one-or more.of•the=following-measures:, ~� i Reorient or relocate the receiving antenna. - " Increase the separation_between the equipment and receiver. t - Connect the equipment into an outlet on a"circuit different from that to which the receiver is connected. - Consult the dealer or an experienced radio/TV technician for help. I t 16. NATIONAL USAGE RESTR1CTI.ONIS- = Some countries,states or provinces,have other electrical codes and standards than stated in this manual.The"installation and usage of the,product shall follow local regulations.The product is intended for use by general public.The product is intended for locations with both restricted access and non-restricted access. -17. -S U PPO'RT- For support, FAQ-, latest.reyised:manual and mole information about GM product"visitGM's,website.or contact"GM: Chevrolet* Buick* GMC* Cadillac* NORTH AMERICA. 1-833-382-4389. 1-833-382-4389 1-8.33-382-43.89 833-223-4227 CANADA*** 1-800-263-3777 1-800-263-3777 1-80Q-263-3r777 1-800-2b3-3777 '1, Hours of Operation: Monday-:'Friday 8am- 12am EST;Saturday-Sunday 12pm-9pm EST { ** Hours of Operation: Monday--Friday 8am-6pm EST "** Select option'0'for EVSE support t 1 PART No. SHEET RM2AUG22 l: ALL INFOfAW77IIOFN,WI THIN ABOVE. Date Revision AUth DR ? BOROER TG BE PPoNTED EXACTLY Title GM Ultiu m'EV Charging Station AS SHOWN ON 85 x 11 WHITE IB 02AUG22 First Rel SAR AHt ,POUND NON-BOND RECYCLABLE User Manual PAPEERR,,PRINT ON�.1SO77HH SIOE9 E%CLUDINGTEMPLAM.TOBE' PART No. SHEET 23 UNITED IN ACCORDANCE WITH ,. GMCfA SPECIFICATIONS. d' 1 �r • s i� i d ht• a i � Y FC-�'�/At4t75 F, � C? JI •� esnc¢rpr - - "v is 00 i J-1<k.E::=+ r i-L L- t ; ,3VAt;At.--F D T'HE -6MMJIV WEAt-T.-' -.A�=. v.. Owl - c � w