Permit Application - Installation Or Modification Of Fire Protection Systems - Santa Clara County
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1FIRE DEPARTMENT
SANTA CLARA COUNTY
FIRE
14700 Winchester Blvd., Los Gatos, CA 95032-1818
EST. 1947
COURTESY & SERVICE
(408) 378-4010 (408) 378-9342 (fax)
PERMIT APPLICATION
INSTALLATION OR MODIFICATION OF FIRE PROTECTION SYSTEMS
PERMIT LOCATION:
Establishment Name: _____________________________________________________________________
Street Address:_____________________________________City: ________________Zip:_____________
Building Permit or Project ID from Building Department: _____________________________________
INSTALLING CONTRACTOR:
(phone number you provide will be the number we call when plans are ready for pick up)
Company Name: _________________________ Address: _________________________________________
Project Manager: _______________________________________ Phone: _____________________________
License Classification: A q C-7 q C-10 q C-16q C-34q C-36q License: ___________________
SCOPE OF WORK: (check all that apply)
qFire Sprinkler ( q New q Modified/ q 13 q 13D q 13R/ # of Heads: ___) qHood & Duct qFire Hydrant
qFire Alarm ( q Installation of Monitoring Equipment
q New q Modified/# of Devises: ____) qDry Chemical
qFire Service Underground
qAlternate Fire Suppression
qClean Agent
qOther ___________
Contract Price for Work: $__________________
Permit/Plan Check Fee: ___________________
WORKERS COMPENSATION DECLARATION:
I hereby affirm under penalty of perjury one of the following declarations: (pick one)
q
I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to
become subject to the Worker’s Compensation Laws of California.
q
I have and will maintain a Certificate of Consent to self-insure for Worker’s Compensation, as provided for by Section 3700 of the Labor
Code, for the performance of the work for which the permit is issued. My Worker’s Compensation Insurance and Policy number are:
Carrier: ____________________Policy No: __________________Applicant’s Signature ______________________ Date ____________________
NOTE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Worker’s Compensation
provision’s of the Labor Code, you must comply with such provisions or this permit will be revoked.
ONE TIME PERMIT PROCESS:
Submit a maximum of three (3) sets of completed plans, to include workers compensation insurance certificate and business license for the city
you are working in; one (1) set of hydraulic calculations, seismic bracing load calculations, specifications, and cut sheets (special arrangements
may be made in advance if more than two (2) stamped sets are to be returned). Provide a separate completed application along with the
appropriate fees for each address. Plans will not be accepted without full payment of fees. Contact the Fire Prevention administrative staff for
the proper fee amount. Checks shall be made payable to "SCCFD". Target plan review turnaround time is ten (10) working days however; unusual
circumstances may dictate a longer turnaround time. A completed permit application is required for all types of work. Commercial fire sprinkler
work on existing systems, which involve fifteen (15) heads or less, may be completed over-the-counter contingent on Plans Examiner availability.
Plans may be picked up or mailed via self-paid postage.
I certify that I have read this application and state that the above information is true and correct. I agree to comply with all city and county
ordinances and state laws relating to building construction, and hereby authorize representatives of SCCFD to enter upon the above-mentioned
property for inspection purposes.
(We) agree to save, indemnify, and keep harmless the Santa Clara County Fire Department against liabilities, judgments, costs, and expenses that
may in any way accrue against said department in consequence of the granting of this permit.
Applicant’s Signature: ____________________________________________________________________________ Date:____________________
Fire protection application/ss/10.27.14
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