15010126-TCOCUIPERTINO
TEMPORARY CERTIFICATE OF OCCUPANCY FORM
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
ALBERT SALVADOR, P.E., C.B.O., BUILDING OFFICIAL
10300 TORRE AVENUE ^ CUPERTINO, CA 95014-3255 0
(408) 777-3228 ^ FAY (408) 777-3333 ^ building(@cupertino.org
APW .3 / U Z
BP #:.� O / 2�
DATF� IS
PROJECT
VALUATION: $ t S 610,0c)
SITE
ADDRESS: %O C/00 Tz,9-/q L Ave-
veOWNER'S
OWNER'SNAME:PHONE
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#:
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FAX #:
MAILING ADDRESS (if different from site address):
❑ APPROVED
CONTRACTOR:///���
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PHONE #: os `f Z 2 0a
FAX #: V8' Zlo Z 23112 -
3yLCONTACT:
CONTACT:
Gi/ Al Grd t t Z21
PHONE #:
FAX #:
TEMPORARY CERTIFICATE OF OCCUPANCY INFORMATION
BOND TYPE: ❑ SURETY BOND AMOUNT (1% VALUATIONVALUATIONBLDBONDS CODEAMOUNT❑ CHECK El CASH BOND OF BOND: 5K min -10K max $ �6O (J I J EDITION:
TCO EXPIRATION
DATE (6 MONTHS MAX): /,s FEE: $286.00/mo TOTAL FEE: $ �"Z [1TEMPOCC]
USE
TYPE OF
CONSTR
FLOOR
AREA
OCC
LOAD
LEVEL
COMMENT
kms 12y l3Z
El APPROVED WITH CONDITIONS"
Public Works
❑ APPROVED
❑ APPROVED WITH CONDITIONS'
Signature: ..... ........ ............ ......... .........
......... Date:......................
t er:
❑ APPROVED
❑ APPROVED WITH CONDITIONS
Signature: ...................... __ .............
................. Date:......................
OTHER DEPARfAkHT I AGENCY APPROVALS: /
Planning/ '.
Signature :........:.... ......... �.......................
Date: .....! .. ...
APPROVED
APPROVED WITH CONDITIONS
ire
Signature: .............. ....................
� , Fl 15
Date: .....e, ............
[]APPROVED
El APPROVED WITH CONDITIONS"
Public Works
❑ APPROVED
❑ APPROVED WITH CONDITIONS'
Signature: ..... ........ ............ ......... .........
......... Date:......................
t er:
❑ APPROVED
❑ APPROVED WITH CONDITIONS
Signature: ...................... __ .............
................. Date:......................
CONDITIONS OF COMPLETION - Attach a letter signed by the contractor and owner of the property
stating the list of items required to be completed for each individual Department before final occupancy
can be granted. Include approximate completion dates for each item.
The undersigned covenant and agree as a condition to the approval of the above request for temporary occupancy to have the building or
buildings complete and in compliance with all building codes, ordinances and regulations and ready for inspection prior to the expiration
date specified. If this Temporary Certificate of Occupancy expires, the total amount of the bond may be forfeited and the non-compliance
may result in an enforcement a tion.
Owner �n (� ,G Contractor
Si nat ......L442LDate:lL� `i' ",.�....... Signature:...
:.. ...... Date:.p.... .�5..
This temporary certificate e sures tha 1 fi protection and life safety systems have been competed, inspected, successfully tested and
)proved for the specific r a f the ui di Iecified above to provide a reasonable degree of safety to the occupants from fire and
.milar emergencies.
Building Official .. ....... .... ......... ................. Print: ......Ake ........ �� .........._.:.... Date:.. ...��.. �. ....
DEPARTMENT ACTT N: After determination, opies to: 1) applica n , 2) permit fife
1'empOccFonn_2013.doc revised 717114