13070018 TCOC(IPFRTINO
4 j `1 ?? - 3=9 ?4+1`4
TEMPORARY CERTIFICATE OF OCCUPANCY FORM /Q
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION co ll
ALBERT SALVADOR, P.E., C.B.O., BUILDING OFFICIAL
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(4n8) 777-3228 • FAX (408) 777-3333 • build ingpcul2ertino.orq
APN 3 - Z BP #: ,307oa
SITE
ADDRESS: Z t l 4 (' t TA 6
OWNER'S NAME:
P1raSCLA ?ak1C-Q"
MAILING ADDRESS (if different from site address):
CONTACT:
CaekR_%tk_W
PHONE*
FAX #: Ik /
PHONE #:
j1RMGT/4r✓ CO FAX#: Y
PHONE #:
FAX #: K
-- �~%I InAKIf%V MCnORAATWIM
PROJECT $ /
VALUATION: l
CIA.
4roS, - _9 a -R ass
a
a 135-3 -! QV -
8 -- 2 2 a 91
V07/c/a-/— //,27
TEMPOKAKY UtK 1 IrII.A 1 C Vr %J""Iurr "�.. �+
BOND TYPE: ❑ SURETY BOND AMOUNT (1% VALUATION gl�Q �P_ [BLDBONDS] CODE
❑ CHECK ❑ CASH BOND OF BOND: 5K min -10K max $ I EDITION:
TCO EXPIRATION 6111 -//
/ FEE: $2$6.00/1110 TOTAL FEE: $ 9 L f'? i I1 TEMPOCC]
DATE (6 MONTHS MAX): 1
USE
TYPE OF
CONSTR
FLOOR
AREA
OCC
LOAD
LEVEL
COMMENT
This temporary certificate ensures that all fire protection and life safety systems have been completed, inspected, successfully tested and
Z l 8
similar emergencies.
-...'� ...............Date:.:..%.2
Z
OTHER DEPAR`fMEN / AGENCY APPROVALS:
anning
Si ... . APPROVED APPROVED WITH CONDITIONS'
nature:... Date:S......
l
ire❑ APPROVED F] APPROVED WITH CONDITIONS`
Signature:....�C.,.. '.k-......1.Y.�'...�C 2..�... Date:....... -..1......
u is Works I ❑ APPROVED APPROVED WITH CONDITIONS`
Signature:..... rylw
....l�t:..... Date:....5'.��..� .
t er. ❑ APPROVED ❑ APPROVED WITH CONDITIONS'
Signature:...............................................I......... Date:......................
*CONDITIONS OF COMPLETION - Attach a letter signed by the contractor and owner of the property PW I14P1fWt,,*6
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. ln1ST%r(,� !�
The undersigned covenant and agree as a condition to the approval of the above request for temporary occupancy to have the building or w�
and regulations
ordinances
buildings complete and compliance with all building codes, 0 9
.s the total amount of the bond may be forfeited and the non-compliance
date speci d. If t T orary Certificate of Occupancy ex l ,
may res i an of r e action.
Owner Contractor 3 - S
�<.
Si nature: .. Dat :. .. ..! ..�..... 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.
-...'� ...............Date:.:..%.2
BuildingOfficial:"... ... .......Print:...<'c__...:.5
...........................
DEPARTMENT AG71UN: Atter oeterminauun, cup— ,u. I I OPP I ai n, -1 rte••••••
and ready for inspection prior to the expiration 6ft
Temp0ccForm_2013.doc revised 717114