13020152 TCOCUPERTINO
TEMPORARY CERCATE OF OCCUPANCY FORM
COMMUNITY DEVELOPMENT D PARTMENT • 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 • buildingpcupertino.org
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BP 1: 13020152
FLOOR
AREA
DATE:
PROJECT PROJECT VALUATION: $ 11,705,455.00
SITE 10095 S. Blaney Ave.
81
A-% A
APPROVED WITH CONDITIONS
ADDRESS:
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❑APPROVED
OWNER'S NAME: Prometheus Real Estate
Gr HONE #:
650245-9394
650 931-3657
FAX #:
Other:
MAILING ADDRESS (if different from site address):
APPROVED
E] APPROVED WITH CONDITIONS
1900 S. Norfolk Street, Suite 150
San Mateo,
CA 94403
CONTRACTOR: Johnstone Moyer Inc.
PHONE #:
FAX#:
5 -57 -6161
650-570-6144
CONTACT: Brice Schillling
PHONE#:
650-762-4486 Cell
FAX #:
TEMPORARY CERTIFICATE OF OCCUPANCY INFORMATION
BOND TYPE: ❑ SURETY BOND AMOUNT (1% VALUATION CODE
$ 10,000.00 (BLDBONDSJ
® CHECK ❑ CASH BOND OF BOND: 5K min -10K max EDITION:
TCO EXPIRATION 286.00
DATE (6 MONTHS MAX): 08/23/14 FEE: $2$6.00/m0 TOTAL FEE: $ [1TEMPOCCj
USE
TYPE OF
CONSTR
FLOOR
AREA
OCC
LOAD
LEVEL
COMMENT
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❑APPROVED
APPROVED WITH CONDITIONS
u is Works
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❑APPROVED
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Signature: ......................................................
Date:.. ..3 ...(.7
Other:
APPROVED
E] APPROVED WITH CONDITIONS
Signature:.......
..... Date: ......................
OTHER DEPARTMENT / AGENCY APPROVALS:
Planning
Signature:............:
_
ate:.. 7:..z.3- /y
❑ APPROVED
APPROVED WITH CONDITIONS
ire
Signature:..........
Date:. . 44F
❑APPROVED
APPROVED WITH CONDITIONS
u is Works
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❑APPROVED
APPROVED WITH CONDITIONS
Signature: ......................................................
Date:.. ..3 ...(.7
Other:
APPROVED
E] 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 undersign d covenant and agree as a condition to the approval of the above request for temporary occupancy to have the building or
buildings com to and in compliance with all building codes, ordinances and regulations and ready for inspection prior to the expiration
date specif If his Temporary Certificate of Occupancy expires, the total amount of the bond may be forfeited and the non-compliance
may result a orcement action.
Owner Contractor
07/18/14 07/18/14
Signature:. ........................................... Date:........................ Signat :........�.............� ..... Date:......................
This temporarycertificate ensures that all fire protection and life safety systems have been completed, inspected, successfully tested and
approved for the pecific area of th uilding specified above to provide a reasonable degree of safety to the occupants from fire and
similar emer en ies. ^
Buildina Offici . .................... ..%... .... ........ %!...... Print: .................. .. .............. P ...... 7.1 ............ ... Date:.. ......7...�
7 ........... ...
DEPARTMENT ACTION: After determination, copies to: 1) applicant, 2) permit file
TempOccForm_2013.doc revised 717114