151200781'x"4 �L Q�xle_,
TEMPORARY CERTIFICATE OF OCCUPANCY FORM Cr
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION •
ALBERT SALVADOR, P.E., C.B.O., BUILDING OFFICIAL
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 //�� l j
(408) 777-3228 • FAX (408) 777-3333 • building(a cugertino.org A iL,"v0X D A
APN(ILIBP
TYPE OF
CONSTR
FLOOR
AREA
#: I �'�/`�
DATE
t Q % .�
VALUATION:
SITE
ADDRESS: �� V V,T J 7
Fire
Signature: ....................................................
jj //�� //-
Date: . .kCJ .
!J6
OWNER'S NAME{� ` 6 / �J 1 „ �O� �/
MX#:PHONE #:06,)-q5qM6,
❑APPROVED
MAILING Al��, (if differentfronlGite add r ss)
Signature: ..........................................................
Date:......................
CONTRACTOR: ,
'
PH NE #:00,0
FAX #:
�(p
CONTACT: � `Q
PHONE #
FAX #:
o
(J
TEMPORARY CERTIFICATE OF OCCUPANCY INFORMATION
BOND TYPE: ❑ SURETY BOND AMOUNT (1% VALUATION S BLDBONDS CODE
ElCHECK ❑ CASH BOND OF BOND: 5K min -10K max)— EDITION:
TCO EXPIRATION
DATE (6 MONTHS MAX): FEE. $286.00/ O TOTAL FEE: $��. [1TEMPOCC]
USE
TYPE OF
CONSTR
FLOOR
AREA
OCC
LOAD
LEVEL
COMMENT
Fire
Signature: ....................................................
jj //�� //-
Date: . .kCJ .
APPROVED
E] APPROVED WITH CONDITIONS'
ublic Works
❑APPROVED
11 APPROVED WITH CONDITIONS'
Signature: ..........................................................
Date:......................
Other:
❑APPROVED
El APPROVED WITH CONDITIONS -
OTHER DEPARTMENT /AGENCY APPROVALS:
Planninq
❑ APPROVED
❑ APPROVED WITH CONDITIONS -
Signature: .........................................................
Date:.......,................
Fire
Signature: ....................................................
jj //�� //-
Date: . .kCJ .
APPROVED
E] APPROVED WITH CONDITIONS'
ublic Works
❑APPROVED
11 APPROVED WITH CONDITIONS'
Signature: ..........................................................
Date:......................
Other:
❑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
)proved for the specific a a of th bU'
_ �cife ..bove to vide.a1easonab.�...........
t f and
�Jf. "�nilar emer encie F n �
BuildingOfficial:...'—�.?!�............. ...........Print: ... TUZJ5UW...........Date:.,
...........
DEPARTMENT ACTION: After determination, copies to: 1) applicant, 2) permit file I
Temp0ccF0r777_2013.doc revised 717114