14040138 TCO45S 32_1
TEMPORARY CERTIFICATE OF OCCUPANCY FORM l 11 `�S
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
ALBERT SALVADOR, P.E., C.B.O., BUILDING OFFICIAL
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
CUPERTINO (408) 777-3228 • FAX (408) 777-3333 • building(a-)cupertino.org
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ALLUATION: $
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TcRe0n0A0V rCRTIFIrATF nF nrrl1PANCY INFORMATION
BOND TYPE: ❑ SURETY BOND AMOUNT (1 % VALUATION(BLDBONDS] CODE
❑ CHECK [I CASH BOND OF BOND: 5K min -10K max $ EDITION:
TCO EXPIRATION FEE: $286.00/m0 TOTAL FEE: $ [1TEMPOCC]
DATE (6 MONTHS MAX):
USE
TYPE OF
CONSTR
FLOOR
AREA
OCC
LOAD
LEVEL
COMMENT
ireAPPROVED
❑ APPROVED WITH CONDITIONS'
Signature:'..
.................. ..... Date:.
PublicWorks
APPROVED
❑ APPROVED WITH CONDITIONS -
ONDITIONS`Signature:.............
Signature: ................................................
Date:......................
t er:
❑ APPROVED
APPROVED WITH CONDITIONS' i
Signature: ............ .............................
Date:...........:::......
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?j — 6 — 5 ❑ APPROVED
APPROVED WITH CONDITIONS'
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ate: ..................1.....
ireAPPROVED
❑ APPROVED WITH CONDITIONS'
Signature:'..
.................. ..... Date:.
PublicWorks
APPROVED
❑ APPROVED WITH CONDITIONS -
ONDITIONS`Signature:.............
Signature: ................................................
Date:......................
t er:
❑ APPROVED
APPROVED WITH CONDITIONS' i
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 actjgn.
Owner r_ t,(nudcwi I
Sianature:.............. ... ... .. ..................... Date' lAb..)Signature:........................................I................. Date:......................
This temporary c rtificate 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.
'.:�.................Date.....Buildin Official:..... ............... .....................I....................Print:.;.. ....,
DEPARTMENT ACTION:- After determination, copies to: 1) applicant, 2) permit file
TempOceForm_2013.doe revised 717114