13020154 TCOK4
CUPERTINO
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
(408) 777-3228 • FAX (408) 777-3333 • building aacupertino.org
V_160,1 115
APN
BP#: 13020154
DATE: 09/18/14
PROJECT $ 1, 232, 112.00
VALUATION:
SITE 10097 S. Blaney Ave.
ADDRESS:
OWNER'S NAMErometheus
PHONE#:650.931.3457
Real Estate Group
P p
FAX#: 650.931.3657
MAILING ADDRESS (if different from site address):
1900 S. Norfolk Street, Suite 150 San Mateo, CA 94403
CONTRACTOR: Johnstone Moyer Inc.
PHONE #:650-570-6161
FAX#: 650-570-6144
CONTACT: Brice Schillling
PHONE#: 650-762-4486 Cell
Date:..... ....z
FAX #:
TEMPORARY CERTIFICATE OF OCCUPANCY INFORMATION
BOND TYPE: ❑ SURETY BOND AMOUNT (1% VALUATIONCODE
❑ CHECK ❑ CASH BOND OF BOND: 5K min -10K max $ (BLDBONDSJ EDITION:
TCO EXPIRATION
DATE (ti MONTHS MAX): FEE: $2$6.00/1'110 TOTAL FEE: $ [1TEMPOCC]
USE
TYPE OF
CONSTR
FLOOR
AREA
OCC
LOAD
LEVEL
COMMENT
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[]APPROVED
APPROVED WITH CONDITIONS'
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❑ APPROVED
APPROVED WITH CONDITIONS-
Signature :............... ..... .............. ..
Date:..... ....z
Other:
Date:....'L!:.�..�
❑APPROVED
r)T411=R nFPARTMFNT I ArFNCY APPROVALS -
Planning
Signature:..... �� %� ..
ate:....y.-.Z�._ ly
❑APPROVED
APPROVED WITH CONDITIONS"
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Date:...... .L.R...I.`{
[]APPROVED
APPROVED WITH CONDITIONS'
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❑ APPROVED
APPROVED WITH CONDITIONS-
Signature :............... ..... .............. ..
Date:..... ....z
Other:
Date:....'L!:.�..�
❑APPROVED
� APPROVED WITH CONDITIONS -
Signature: ............ ................................
*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 undersig a covenant and agree as a condition to the approval of the above request for temporary occupancy to have the building or
buildings co 1 to and in compliance with all building codes, ordinances and regulations and ready for inspection prior to the expiration
date specifift this Temporary Certificate of Occupancy expires, the total amount of the bond may be forfeited and the non-compliance
may result 14 a forcement action.
Owner ��rr.� Contractor 09/18/14
Signature:.. .c. .............................................. Dater .�? gnature:...BriCe...D......Schillirn9...Date:......................
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This temporary r ificate ensures that all fire protection and life safety systems have been completed, inspected, successfully tested and
approved for the specific area of the building specified above to provide a reasonable degree of safety to the occupants from fire and
similar emergencies.
S
1100J.—
Buildina Official: ....................Y............................................. Print:..l'�'../ ..S n... ........................ Date:.... ....:.......... �`i
...
DEPARTMENT ACTION: Aftef determination, copies to: 1) applicant, 2)/permit file
TempOccForm_2013.doc revised 717114