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APPLICATION FOR CERTIFICATE OF OCCUPANCY
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•buildinq(c�cupertino.org
COMPLETE A SEPARATE APPLICATION FOR EACH BUILDING:
PROJECT ADDRESS APN# DATE
10055 Miller Ave. Suite 101 & 102 CUPERTINO, CA 02/20/2020
oWNERNAMEJacqueline Lo PH�N�408-252-3876 E-MA„jklo_classical@yahoo.com
STREETADDRESS�OO55 MIIIer AVe. SUIte �O� <-ITY, STATE,ZIPCupertino, CA 95014
CONTRACTORNAMEBIUe NOI�I�@rl� BUIICI@CS IC�C. PHONE916-218-2014 E-MAILmorgan@bluenorthernbuilders.com
STREETADDRESS34H TaraVal St. CITY, STATE,ZIPS81l FraIICISCO, CA 94116
MAIL CERTIFICATE TO: (Please allow up to 10 business days for delivery):
CONTACT NAME PHONE E-MAIL,
Jacqueline Lo 408-252-3876 �klo_classical@yahoo.com
sTaEETA��REss 10055 Miller Ave. Suite 101 c`TY, STATE,Z�PCupertino, CA 95014
LIST ALL BUILDING PERMITS ISSUED FOR PROJECT:
PERMIT NUMBER DATE FINALED INSPECTOR SCOPE
� B-2018-2106 02/10/2020 Jeff Greet Dental TI
2
3
4
NOTE: Please attach a copy of BOTH SIDES of the signed inspection job card to this application.
- OFFICE USE ONLY-
SPECIAL STIPULATIONS OR CONDITIONS: CHECKLIST: �
Copy of Job Card Attached(both sides)?
Permit signed off in system? �
No other permits open or expired in system? �
Verification of payment for certification?
Cof'O Application.doc revised 08/OS/18
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O�VNF72'S NAME:Lee Fujinrota L�&Assocs LLC; II2NIITNU 8-201&-210fi
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UNDERFLOOR MECIIA?VECAL MONDAY'I'HROUGHTHURSDAI'OR BEItiVFII�;7:30 A.M AND 2:30 P.iV1 O\FRIDAY.
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INTE:RIOR LATH PAD/SET$ACK C�RTIFICATION
E�7'E�RIOR[ATH EPDXYOBSERVATION LETTER
SCIZATCH COAT DF,PAItTM11E\T Fi1�AlS
S WIMD�pNG POOL PLANNING-CALL(408)777-3308
POOL PRE-DECK PUBLIC W t3I2KS-CALL(408}79'7-3354
YOOL PRE-GCJl�i1TE FIRE-CALL(403)378-4010
POOL PR�PLA STIIZ SAN[TARY-CALL(403)'S3-'071
PCX�L DFMOLITION BU/LDING FNL41,S
RooFt!�G MEC7If1NICAL •7 l^r
ROOF PRE-INSPECTION EL.ECTRICAL
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� CUPERTINO Receipt No.: 265039
10300 TORRE AVE
„� Receipt Date: 02/24/2020
'*y
���,��,�i�� CUPERTINO, CA95014
Telephone: Cupertino, CA 95014
RECEIPT
RECORD&PAYER INFORMAT/ON
RecordlD: B-2018-2106
Record Type: Magnet Converted
Property Address: 10055 MILLER AVE,Suite#101,CUPERTINO,CA 95014-3468
Description of Work: DR LO DENTAL CARE-T.I.-(2643 SF)COMBINE SUITE 101 WITH SUITE 102
Payer: KAPPLER INC(HOLGEN KAPPLER)
Applicant: N/A
Kappler Inc.
615
S College St
Charlotte,NC 28202
PAYMENT DETAIL
Date Payment Method Reference Cashier Comments Amount
02/24/2020 Credit Card HALEYM $357.00
FEE DETAIL
Fee Description Invoice# Quantity Fee Amount Current Paid
Occupancy-Certificate of Occupancy/Compl 50085 1.00 $357.00 $357.00
$357.00 $357.00
AA_Receipt_Template.rpt Print Date:02/24/2020 Page 1