Form Ds -163 - Affidavit For Fire Alarm Alterations Or Tenant Improvements
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Affidavit for Fire Alarm
City of San Diego
Development Services
DS-163
Alterations or Tenant
1222 First Ave., MS-401
San Diego, CA 92101
Improvements (TIs)
(619) 446-5000
A
2013
pril
The purpose of this affidavit is for designers/contractors to obtain a “no-plan permit” for fire alarm systems when
the scope of work is limited to the addition or alteration of 0 – 4 fire alarm devices and/or appliances in existing
buildings. By signing this affidavit, the fire alarm designer/contractor declares that they are not altering or add-
ing more than four (4) devices/appliances in an existing fire alarm system and that the proposed work complies
with the requirements in National Fire Protection Association (NFPA) Standard 72.
SECTION I: GENERAL INFORMATION
Project Name:
Building Project Number:
Tenant Name:
Building Permit Approval Number:
Job Address:
Suite Number:
Check Box Corresponding to the Number of Proposed or Relocated Initiating Devices or Notification Appliances:
q
0 Devices/Appliances (Complete Section II)
q
1 - 4 Devices/Appliances (Complete Section III and circle the type(s) below)
• Strobes
• Speakers
• Manual Fire Alarm Boxes
• Horn/Strobes
• Speaker/Strobes
• Duct Detectors
• Mini-Horns
• Smoke Detectors
• Sprinkler Waterflow Devices
SECTION II: ZERO (O) DEVICES/APPLIANCES PROPOSED OR ALTERED
(To be completed by general contractor or agent of general contractor)
Contractor Name:
Telephone:
Fax:
Address:
City:
State:
Zip Code:
E-mail Address:
State License No.:
License Class:
Licensed Contractor’s Declaration: I hereby affirm under penalty of perjury that I am licensed under provisions
of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is
in full force and effect.
Print Name: ______________________________________________
Date: ___________________________
Contractor Signature or authorized agent: ______________________________________________________________
I, _______________________________________________________________, certify that this Tenant Improvement (TI)
does not trigger any upgrades to the existing fire alarm system per the California Building and Fire Codes. In ad-
dition, I certify that the positions of the fire alarm devices and appliances relative to architectural features such as
soffits, beams, partitions, walls, etc. comply with the applicable edition of NFPA 72. Final approval is subject to the
final inspection.
Printed on recycled paper. Visit our web site at
Upon request, this information is available in alternative formats for persons with disabilities.
DS-163 (04-13)
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