B-2016-1352 TCO FORM GOOD TILL 5-21-2016CUPERTINO
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 • buildin4iNcupertino.orq
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OWNER'S NAME:
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FAX #:
MAILING ADDRESS (if different from site address):
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PHONE #:
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TEMPORARY CERTIFICATE OF OCCUPANCY INFORMATION
BONDTYPE: ❑SURETYBOND
AMOUNT
(1%VALUATION //��''''y�T��
$ UW (BLDBONDSj
CODE
❑ CHECK El CASH BON
F BOND:
5Kmin-10Kmax
EDITION:
TCO EXPIRATION
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FEE: 0/mo
256.
TOTAL FEE: $ [1TEMPOCCj
DATE (6 MONTHS MAX): V C.Jr
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USE
TYPE OF
CONSTR
FLOOR
AREA
OCC
LOAD
LEVEL
COMMENT
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OTHER DEPARTMENT / AGENCY APPROVALS:
Panning
...............................................
Date:.......................
❑ APPROVED
El APPROVED WITH CONDITIONS -
Fire
re
Signature: ..
........ Date: ...
r' . eAPPROVED
❑ APPROVED WITH CONDITIONS"
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❑ APPROVED
❑ APPROVED WITH CONDITIONS -
Signature: .... .
.................... Date:......................
Other: er;
]APPROVED
El 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 action.
Owner Contractor
Signature: ............................................ ............ Date:........................ Signature:.......................................................... Date:......................
This temporary certificate 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.
Buildin Officia Print �'r-"l-� .5P � 1 Date' 7..:.R�..L^/..e......
DEPARTMENT ACTION: After determination, copies to: 1) applicant, 2) permit file
7'empOccForm_2013.doc revised 717114