Fill - Free fillable EXPEDITED BUILDING PERMIT FOR WALL- MOUNTED TELEVISION/MONITOR (California) PDF form

How to Guide Series

A Companion

Document to the

OSHPD FREER

Manual

EXPEDITED BUILDING

PERMIT FOR WALL-

MOUNTED

TELEVISION/MONITOR

BRACKET

FOR SINGLE STORY

WOOD FRAME

SKILLED NURSING

FACILITIES &

INTERMEDIATE

CARE FACILITIES

(OSHPD 2 Buildings)

December 2015

EXPEDITED BUILDING PERMIT GUIDE FOR WALL-MOUNTED

TELEVISION/MONITOR BRACKET

The Expedited Building Permit Guides are companion documents to the OSHPD Field Review,

Exempt, and Expedited Review (FREER) Manual and are intended as general reference

guides and/or checklists to facilitate repair, maintenance, minor renovation/remodeling, or

installation of certain equipment projects.

The Expedited Building Permit Guides are intended only for single-story OSHPD 2 Skilled

Nursing Facilities (SNFs) and Intermediate Care Facilities ( ICFs) that are of wood frame

construction and excluded from the definition of “Hospital Building” in the California

Administrative Code (CAC) Article 2, Section 7-111.

The use of this Expedited Building Permit Guide is made available for use at the discretion of

the facility owner. The OSHPD does not mandate the use of the Expedited Building Permit

Guide for any condition. Use of project-specific design and construction documents prepared

by a California licensed design professional in lieu of using the Expedited Building Permit

Guide is always acceptable, and in some cases, may be required.

This Expedited Building Permit Guide gives no consideration to suitability for use in a specific

application, compatibility with other building systems, appropriate use of materials or design,

appearances, etc. The facility owner and/or his/her authorized agent shall review all such

qualities, features, and/or properties to ensure compliance with the California Building

Standards Code and all applicable local codes and ordinances, appropriate integration with

other building systems, and proper design for the project-specific conditions and installation,

etc.

While not mandatory, OSHPD recommends the facility have a California licensed architect or

engineer, or a California licensed contractor assist in the review of the code compliance

checklist provided in the Guide. In this manner the facility will have a better understanding of

the scope of work that may be required for a code compliant project prior to beginning the

work.

TELEVISION (TV) / MONITOR BRACKET INSTALLATION

A wall-mounted Television (TV) / Monitor bracket installation requires a Building Permit

but may be exempt from the plan review process in accordance with Health & Safety Code

(H&SC) Section 129875. Simple installation of TV/Monitor brackets in qualifying OSHPD 2

SNFs and ICFs may be considered exempt from plan review, if certain criteria are met. This

Expedited Building Permit Guide presents those criteria in a checklist format for general

assessment of the specific project conditions. Installation of a TV/Monitor bracket without a

permit is subject to an investigation fee, submittal of a project to the Office for plan review,

demolition and/or rework of defective non-code complying work, etc. in accordance with the

California Administrative Code, Title 24, Part 1, Section 7-128 “Work Performed without a

Permit”.

The facility owner or his/her authorized agent should review this checklist with the OSHPD

Compliance Officer to determine program eligibility, to assess the specific project conditions

and determination of possible approaches to the application, review, permitting, and

construction process. Possible approaches include, but are not limited to:

Installation with Minor Work – For relatively simple installation of a wall-mounted

TV/Monitor bracket, where minor modifications (no structural work beyond that which is

-2-

provided in this guide or shown on OSHPD Preapproved Details (OPDs), OSHPD

Preapproval of Manufacturer’s Certification (OPM)), repairs, or remedial work is necessary

to bring the system into compliance with current code. The facility may have the work

performed by its maintenance staff or by a California licensed contractor.

Installation with More than Minor Work -- For more involved installations of a wall-

mounted TV/Monitor bracket, where modifications, repairs or remedial work is necessary to

bring the system into compliance with current code (such as structural work beyond that

shown on details in this guide, OPDs, or OPMs)), the facility shall involve a design

professional. Where this work is of sufficiently limited scope, field review by the OSHPD

Compliance Officer can be used, or it may qualify for review by the OSHPD Rapid Review

Unit (RRU), or it may qualify for an over-the-counter review by the OSHPD Regional

Architectural & Engineering Unit.

Determination of Eligibility – Determination of eligibility and appropriate permitting process is

the responsibility of the OSHPD Regional Compliance Officer. Facilities are encouraged to

work with their Compliance Officer prior to assuming eligibility or an approach to permitting.

Inspections – The approved Inspector of Record (IOR) must inspect the work. Interim

inspection will be required when walls, ceilings or other construction materials will cover the

finished work. Any deficiencies, identified through inspection, shall be corrected before use of

the system is permitted. A “Construction Final” issued by the OSHPD Compliance Officer is

required prior to use of the TV/Monitor bracket. Responsible parties shall file Verified

Compliance Reports in accordance with the requirements of the Testing, Inspection, and

Observation (TIO) Program. (See Appendix A)

Manufacturer's Written Installation, Operating, and Maintenance Instructions -- The

installation shall comply with the manufacturer’s written installation instructions. The installer

(facility’s maintenance staff/contractor) shall leave or submit to the Compliance Officer the

manufacturer's installation, operating, and maintenance instructions in a location on the

premises where they will be readily available for reference and guidance for the IOR, OSHPD

staff, service personnel, and the owner or operator.

-3-

New Project/Building Permit Application Requirements

Step 1. Verify that the project is eligible for this program. Consultation with the OSHPD

Compliance Officer is recommended.

Step 2. Download and print the Expedited Building Permit Guide and complete the Wall-

mounted TV/Monitor Bracket Code Compliance Checklist beginning on page 4 of

this Guide and complete the Application for New Project/Building Permit beginning

on page 12 of this Guide. These documents may be filled-in manually or

electronically.

Step 3. Prepare a plan/sketch showing the location(s) and elevation(s) of where the

TV/Monitor bracket(s) will be installed.

Step 4. Print two (2) complete sets of the entire package (the “How- to Guide” with completed

checklist, applications and the plan/sketch), sign and date, where required, and mail or

deliver to:

For construction in Northern California, submit to:

Office of Statewide Health Planning and Development

Facilities Development Division

400 R Street, Suite 200

Sacramento, CA 95811

(916) 440-8300 phone

(916) 324-9188 fax

For construction in Southern California

, submit to:

Office of Statewide Health Planning and Development

Facilities Development Division

700 North Alameda Street, Suite 2-500

Los Angeles, CA 90012

(213) 897-0166 phone

(213) 897-0168 fax

Upon issuance of the building permit for the project by OSHPD, you may submit a

construction start letter and begin installation of the TV/Monitor bracket(s).

-4-

r

I

WALL- MOUNTED TV / MONITOR BRACKET

CODE COMPLIANCE CHECKLIST

NOTE: The OSHPD Compliance Officer will field verify compliance with this checklist and additional

work may be required to bring the installation into code compliance if found to be deficient.

PROJECT DESCRIPTION

1. Is the TV/Monitor Bracket installation project located in a single-story Skilled

Nursing or Intermediate Care Facility building of wood-frame construction?

2. Is the project only for wall-mounted TV/Monitor bracket(s) installation?

3. Does the Estimated Construction Cost or Contract Amount exceed $50,000?

4. Is a sketch of floor plans and wall elevations indicating area(s) of work and

location(s) where the TV/Monitor bracket(s) are to be installed provided?

5. Are the details for installation of the TV/Monitor Brackets similar to those

provided in this Guide or an OSHPD pre-approved bracket (OPM)? (To be

verified by the OSHPD Compliance Officer for applicability).

GENERAL REQUIREMENTS

6. Contractor. Will work be performed by a contractor licensed by the California

Contractors State License Board?

TV / MONITOR BRACKET INSTALLATION REQUIREMENTS

7. Are the walls supporting the TV/Monitor brackets full-

height studs connected at top

by ceiling or roof framing members and anchored at the floor/slab?

Commentary: This program may not be used for installation of TV/Monitor

brackets to walls that are not full height from floor to ceiling. Wall mounting

surface

should have a maximum 5/8” thick drywall.

8. If installed in a corridor, will the TV/Monitor project horizontally from either side of

a corridor more than 1½ inches into the required width of an exit access corridor?

(Corridors serving patient areas require an exit width of 8 feet.)

9. Is the Flat Display Mounting Hardware coordinated with the TV/Monitor to be

installed (e.g. VESA Mounting Interface Standard, etc.) and any

electrical/communication systems?

Compliance

Yes

No

NA



10. Will the new monitors be used for access to an existing Electronic Medical

Records (EMR) system?

Commentary: Monitors associated with the introduction of a new EMR system are

not qualified for this program and must be submitted to the office for office review.



-5-

Clear Checklist

Compliance

Yes No NA

11. Will the leading edge of the TV/Monitor be installed more than 27 inches and not

more than 80 inches above the finish floor or ground and not protrude more than

4 inches horizontally into the circulation path of any room?

CX)

N

/\

I 8

><

N

12. If the installation includes a monitor intended for interactive communication

either by the patient or by medical staff (e.g. Electronic Medical Records) will it

comply with either 12.a or 12.b as indicated below? ( If yes, check the box for

the applicable requirements)

12.a The installation includes a non-interactive display and a keyboard

and/or other input interface. This installation will allow the centerline of the

display to be adjusted to a height of 52 inches, or less, above the floor

level. The keyboard interface may be part of the unit and retractable to

meet the conditions of Item #11 above, when not in use, or be wireless. If

the keyboard interface is part of the unit, it can be adjusted to

accommodate use by those seated in a mobility device (e.g. wheelchair,

scooter, etc.). (Retractable keyboards may not be used to meet the

conditions of Item #11 above.)



-6-

Compliance

Yes No NA

12.b The installation includes an interactive display (e.g. touch-screen) as

the input interface. This installation will allow the top of the display to be

lowered to a height of 48 inches above the floor level to accommodate

unobstructed side reach as shown below. Clear floor space must be no

more than 10 inches from the wall surface to be considered “unobstructed.”

OR



-7-

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Compliance

Yes No NA

13. TV/Monitor brackets' support and attachments are pre-approved by OSHPD

through OSHPD OPM Certification. Select the applicable OPM below to be used.

(To be verified by the OSHPD Compliance Officer for applicability).

The following are currently approved OPMs for TV/Monitor brackets:

13.a http://www.oshpd.ca.gov/FDD/Pre-Approval/OPM-0049-13.pdf

13.b http://www.oshpd.ca.gov/FDD/Pre-Approval/OPM-0061-13.pdf

13.c http://www.oshpd.ca.gov/FDD/Pre-Approval/OPM-0075-13.pdf

13.d http://www.oshpd.ca.gov/FDD/Pre-Approval/OPM-0084-13.pdf

Commentary: Requirements for and verification responsibilities of a

Structural Engineer, as required in the OPM Certification, shall not apply to

projects that qualify for “Installation with Minor Work” under this Expedited

Building Permit Guide.

14. Will the TV/Monitor bracket wall plate be anchored to two wood studs or wood

blocking in accordance with the details below? Select either 14.a or 14.b as

applicable:

NOTE: Pre-drill all holes with a bit 1/16” smaller than lag screw dia. All

anchors must be into wood studs or solid wood blocking. Anchorage to

gypsum board or other wall finish material is not acceptable.



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For anchor locations not coinciding with existing wood studs, blocking to be

added as shown below

2x wood stud

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blocking, Douglas

Fir I or Better

A34 Light gage

framing clip (Do

not omit any

fasteners)

WALL BLOCKING DETAIL

14.a The TV/Monitor will have an articulating mount. The weight of the

TV/Monitor will not exceed the weight shown in the table below for the

maximum length of the bracket’s extension arm or as shown in the

manufacturer’s written instructions, whichever is less.

Stud

, 4

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(inches)

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12

15

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(l

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50

35

Maximum arm extension allows for

movement

all directions.

14.b The TV/Monitor will have a tilt or flat mount (no extension arm) and will

not exceed 150 lbs. or the maximum weight as shown in the manufacturer’s

written instructions, whichever is less.

15. Will the TV/Monitor bracket wall plate will be anchored to one wood

stud in accordance with the details below? Select 15.a or 15.b as

applicable.

NOTE: Pre-drill all holes with a bit 1/16” smaller than lag screw dia. All

anchors must be into wood studs or solid wood blocking. Anchorage to

gypsum board or other wall finish materials is not acceptable.



-9-

Compliance

Yes No NA

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15.a The TV/Monitor will have an articulating mount. The weight of the

TV/Monitor will not exceed the weight shown in the table below for the

maximum length of the bracket’s extension arm (circle the applicable weight) or

as shown in the manufacturer’s written instructions of lbs., whichever

is less.

M

ini

mum

Scr

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Spa

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ch

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must

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swivel.

15.b The TV/Monitor will have a tilt or flat mount (no extension arm) and will

not exceed 100 lbs. or the maximum weight as shown in the manufacturer’s

written instructions of lbs., whichever is less.

NOTE: The details provided herein may require a larger and/or longer

fastener, additional blocking, etc. that exceeds the manufacturer’s

requirements. Seismic (earthquake) loads have been factored into the

design of these details and therefore, the most stringent requirements

between these details and the manufacturer’s requirements must be

followed.

Any “no” answer in the Code Compliance Checklist may require additional work. The

requirements based on your submitted answers will be communicated to you by the

OSHPD Regional Complaince Officer.



I

I I

-

APPENDIX A

OFFICE OF STATEWIDE HEALTH PLANNING AND DEVELOPMENT

FACILITIES DEVELOPMENT DIVISION – www.oshpd.ca.gov/fdd

400 R Street, Suite 200 ~ Sacramento, California 95811 Phone (916) 440-8300 FAX (916) 324-9188

700 N. Alameda Street, Suite 2-500 ~ Los Angeles, California 90012 Phone (213) 897-0166 FAX (213) 897-0168

Testing, Inspection and Observation Program

2013 California Building Standards Code – OSHPD 2

D

CONSTRUCTION OBSERVATION AND REPORTING

FOR

OFFICE

USE ONLY

REQUIRED CONSTRUCTION

OBSERVATION

(See “PERSONAL KNOWLEDGE” as

defined in California Administrative Code,

Section 7-151)

VERIFIED COMPLIANCE REPORT REQUIRED AS INDICATED

(Form OSH-FD-123)

Ref.

No. *MILESTONES GEOR AOR SEOR MEOR EEOR

CONT

or

O/B

SP

INSP IOR

OSHPD

FDD

FINAL VERIFIED COMPLIANCE

REPORT AT COMPLETION

X X

E

FOR OFFICE USE ONLY

OSHPD Field Acceptance:

Name: Date:

- 11 -

Clear TIO Form

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prov

id

ed

tha

t the i

mp

r

ovements

are not int

ended

or offered

fo

r

sa

le.

tf

, however,

th

e building or i

mp

r

ov

ement is

so

ld ~

th

in one ye

ar

of

comp

le

ti

on,

th

e Owner-

Bu

il

de

r

wi

ll

h

ave

t

he

bu

r

den

of

prov

i

ng

tha

t

rt

was

not

bu

i

lt

or i

rrc>

roved

for

th

e purpose of

sa

le.).

D I

am

exemp

t under

Section

: Bui

ld

ing and Pr

ofess

ions

Code

for

th

is

reason

:.

___________

_

D I,

as

o

wn

er

of

the

property,

am

ex

dusi

vely

con

t

ract

i

ng

with

li

censed

co

n

tractors

to

cons

tru

ct

th

e

project

(

Sec

.

7044

,

Busi

n

ess

and

P

rofess

i

ons

Cede

:

The

Co

n

tracto

r'

s Sta~

Li

ce

n

se

Law

d

oes

no

t

app

ly to

an

owner

of

property

Who

builds or i

mp

r

oves

th

er

eon

,

and

who

con

t

racts

for the

pro

j

ects

with a

con

t

ractor(s

) li

censed

pursua

nt

to

th

e

Con

tractol's

Sta

te

License

Law.).

By

my

sig

n

ature

below

I

acknov.ledge

tha

t, I

ca

n

not

l

ega

ll

y

se

ll

a

stru

cture that I h

ave

bu

ilt

as

an

owne

r

-bu

il

de

r if

rt

ha

s

not

been

cons

t

ruc

t

ed

in

its

en

ti

re

ty

by li

censed

con

t

ractors

. I un

ders

tand

that

a

C0fYf

of the

appl

i

cab

le law,

Sectio

n

7044

of the Busi

ness

and

P

rofess

i

ons

Cede

, is

ava

il

ab

le u

po

n r

eq

uest

when

th

is

app

li

ca

t

ion

is

subm

itt

ed

or at

th

e f

ol

l

owing

webstte

: h

ttp

:/

/WMv

.l

eg

in

fo

.

ca

.

gov

.

Sign

at

ure of L

egal

Owne

r

or

Authorized Agent

,_

________________

--'

Da

te

______

_

STA

TE

OF CALIF

OR

NIA -

HEAL

TH

ANO HUMAN S E

RV

ICES AGENCY

OS

H-F

O-

XXX

- TVl).10NITOR BRACK

ET

{

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v

08/

06

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- 13 -

,~

OFFICE

OF

STATEWIDE

HEALTH

PLANNING AND

DEVELOPMENT

FACILITIES

.:l,j

;i~

DEVELOPMENT

DIVISION

Worker's Compensation Coverage

WO

RKER

S'

CO

MPEN

SATIO

N

DE

CLARATION (Secti

on

3800

,

Labo

r Code):

WARNIN

G:

FAI

LUR

E TO

SECUR

E WOR

KERS

' COMPENSA

TI

ON

COVE

RAG

E IS UN

LA

WFUL,

AN

D SHALL

SU

BJ

ECT

AN

EMP

LOYER

TO CRIMINAL

PE

NAL

TI

ES

AND

CIVIL

FI

NES UP

TO

ON

E HUND

RED

THOUSA

ND

DOLLA

RS

($100,

000

), IN

ADDITIO

N TO T

HE

COST

OF

COMP

E

NSATIO

N,

DAMAG

ES AS P

ROV

I

DED

FOR IN

SEC

TI

ON

3706 OF

THE

LABO

R COD

E,

I

NTE

RES

T,

AND

A

TT

O

RNEY'S

FEES.

I hereby a

ffi

rm under

pen

alty

of

pe

rj

ury ~

of

the

fo

ll

owi

ng

de

cla

rations:

□

Exempt: I

ce

rtify that, in the pe

rf

ormance

of

the work for

v.11

ich this

permrt

is issued, I

sha

ll n

ot

employ any person in any

ma

nner

so

as

to

become

subject to the

wo

rkers'

compensa

ti

on laws

of

Ga

lifomia, and agree t

ha

t, if I sh

ou

ld

become

subject to the

workers'

compe

n

sation

pr

ovis

ions

of

Section 3700

of

the Labor Code, I

sha

ll fo

rth

v.it

h

comply

with

those provisions.

D Insured through Carrier: I have

and

wi

ll

ma

intain workers'

compe

n

sation

insuran

ce

. as requi

re

d by Section 3700 of the

Labo

r

Code, for the pe

rf

orma

n

ce

of

the

wo

rk for

wh

i

ch

this

perm

it is issued.

My

workers

'

compensa

ti

on insu

ra

nce carrier

and

po

fi

cy

number a

re

:

Policy #

______

_ Insu

rance

Game

r

____________

_

Expirati

on

Date

_____

_

Insurance

Agen

t Name

__________

_

Insu

rance

Agen

t

Phone

_______

_

0

Copy Attached

D Self-insured: I

hav

e and

wi

ll

ma

in

ta

in a

ce

rtificate

of

consent to self-i

nsu

re for

WOlkers

'

compe

n

sa

tion, i

ss

ued by the Di

rec

tor of

Industrial Relations

as

provided for by

Section

3700

of

the

Labo

r

Cod

e, for the pe

rf

orma

nce

of

the work for

wh

i

ch

th

is

perm

it is

i

ssued.

Ce

rti

ficat

e#

_________________

_

0 Copy Attached

Applicant's Signature_

-:

============

=-

--------

=

=--

Costs

Cost Type O

Es

ti

mated

0 Contract

R

easo

n

Constructi

on

Costs

(

exc

ludin

g

F,x

ed

equ,Pmen~ imaging

equ

ipment,

design fees, i

nspec

6on fees, a

nd

off

-site im

pro

vemen

ts)

No

tes:

For

SB 1838 projects, t

his

a

mount

must

not

exce

ed

$50

,

000

Fo

r

Inc

rement

ed

proj

ects

include the

combi

n

ed

coots

for

a

ll

increments

Fixed Equipment Costs

(

st

erilizers,

ch

iNe

rs

, boilers, e

tc

., e

xclud

ing

insta

lf

afion)

Not e:

See

Instructions

for

F

ee

ln

.'"

onna

tion

STA

TE

OF CALIF

OR

NIA -

HEAL

TH ANO HU

MAN

SE

RV

ICES AGENCY

OS

H-F

O-

XXX

-

TV

/

MO

NITOR B

RAC

K

ET

(

Re

v 0

8/

06

114)

Date_

-=

====

-

os

Dpd

- 14 -

F

FICE

OF

STA

TE

W

ID

E HE

ALTH

PLA

NN

ING ANO DE

VELO

P

ME

NT F

ACI

LI

TIES

DEVELO

P

ME

NT

DIVIS

I

ON

Ap

pli

cat

i

on

Spe

ci

fi

c

Info

rma

t

io

n - I

ns

pe

cto

r of

Record

OS

HP

D Celtificati

on

Nu

mbe

r.

____________

Cl

ass

D A D B D C

/Ve

you

enga

g

ed

in a

oos

in

ess

or ot

he

r

employme

nt

th

at

reQ

ui

res

a

po

rt

ion of

you

r ti

me?

D Y

es

D

No

tt

yes,

desc

ri

be

CE

RTI

FICATI

ON

OF

APPLICANT

for

INSP

E

CTOR

OF

RE

CORD

I h

ere

by certify that all an

swers

to

th

e Ques

ti

ons on

th

is f

onn

are

true

, and I agr

ee

and under

sta

nd

tha

t any

misstat

emen

t of

ma

te

rial

fa

ct

co

n

tai

n

ed

in this a

ppl

ica

ti

on

v,;11

be

suffic

ient

cause

for my di

sm

issal

on

th

is

pro

j

ect.,

and

poss

ible

su

s

pension

or rev

oca

ti

on of

my

Hosp

i

ta

l I

nsp

ecto

r

Ce

rti

fi

ca

tion. If I unde

rta

ke

ad

d

ition

al work

othe

r than

sta

t

ed

herei

n,

I

v,;

1

no

ti

fy the

OYKIE!

r, the Archit

ect.

an

d/o

r

Eng

in

ee

r,

and

the

Office of Stat

e..

de

Hea

l

th

Plan

ning and

De

vel

Ol)llle

nl

without

d

el

a

y.

If ap

poi

nt

ed

, I

v,;

n

accep

l

th

e

respo

nsibil

itie

s of In

spe

ct

or of R

ecor

d on

th

e

above

me

n

ti

oned

proje

ct

and

v,;

1 dis

ch

arge

th

e duties i

mposed

upon

me

by all appli

ca

ble

secti

ons

of

th

e Health and

Sa

fety

Code.

Sig

na

tu

re~

______________________________

Date

LE

GA

L

OWN

ER

Th

is

person

is

be

i

ng

e

mpl

o

yed

by

th

e

hospital

su

bj

ect to

the

app

r

oval

of the ar

chrt

ect.

struc

tu

ra

l

eng

in

ee

r, or o

th

er

app

li

ca

ble prof

ess

ion

al

eng

ineer, and

OS

H

PD

, and

is

Qua

lifi

ed

and

ab

le to

pro

vi

de

compe

tenl

adeQ

ua

te and conlinu

ous

i

nspectio

n d

uri

ng

cons

t

ru

c

ti

on

of

th

is

pro

j

ect

.

Pri

nted N

ame

______________________

li

tle

Sigr~h,

ra

n ~t c

PROF

ESS

I

ONAL

Th

is

person

k

nown

to

me

, is Qualifi

ed

, and is

sa

tisf

acto

ry to

me

as

an I

nspector

of

Reco

rd

on

th

is prcject.

Sig

na

tu

re of

Arc

hrt

ect

or

E

ng

ineer in R

espons

i

bl

e

Ch

ar

ge

________________

Date

Sig

na

tu

re of

Structura

l E

ng

ineer Date

O

FF

ICE USE O

NL

Y

OSHPD

APP

R

OVA

L

{Required on prqects lh.ll in

dude

pml

.11)'

17

av

i

ty

andlor l

at

eral load el

em

ents/systems)

Pri

nted

Name

_____________________

T

rt

le

E

nc

l

osu

r

es

Nu

mber

of

Copi

es

En

closure Type

Nu

mber

of

Copi

es

En

closure Type

H

ow-

To

Gu

i

de

#2 ,.;th

Comp

liance Ch

eck

list

Pl

an

s or sket

ch

sh

ov.;

ng the locations and elevati

ons

2

corrc,

l

ele<I

--=----

Celtifi

ca

te of Insu

ra

nce

fr

om

a

Cal

if

orn

ia li

ce

nse

d

2

co

nt

rac

tor or

-----

F

or

construction

in

Northern

California

, submit

to:

Offi

ce

of Statewi

de

Health Pla

nn

ing and Devel

op

ment

F

ac

il

it

ies Development Divisi

on

400

R St

reel

Su

it

e

200

Sacramento,

CA

95811

(91

6)

440-8300 phone

(916)

324

-91

88

fa

x

STATE

OF

CALI

F

ORNIA

- HE

AL

TH

ANO

HUMAN SE

RV

ICES

AGENCY

OSH

·F

D-

XXX

·

TV

/

MO

NITO

R

BR

ACKET

(

Re

v 08/06/14)

--=2

____

of

tv/mo

n

tt

or b

rac

ke

t(

s) lo

be

inst

al

l

ed

For

construction

in

Southern

California

, submit to:

Offi

ce

of State

wi

de

Health Planning an d Developm

en

t

Faciliti

es

Developm

en

t Division

700 North

Al

ameda St

reel

S

ui

te 2-500

L

os

Angel

es

,

CA

90012

(213) 897-01

66

phone

(213) 897-01

68

f

ax

o s

Dpd

- 15 -

16

OFFICE

OF

STATEW

IDE

HEALTH

PLANNING

ANO

DEVELO

PMENT

FACILITIES

DEVELO

PMENT

DIVIS

I

ON

Letter of Authorization (If app

li

cation is made

by

an

Project #:

Age

nt on beha

lf

of the Legal Owner/Administrator)

T

o:

Office

of

Statewide Health Planning and Development

I her

eby

autho

ri

ze :

(Name)

_________

(Title)

To be known

as

the "

Age

nt

for

Legal

Ap

plicant'' in accor

da

nce with the

Application

for

N

ew

Proj

ec

t and

as

the "Legal Owner, or

Au

thorized Agent• on

Building Permit, P

os

t

Ap

proval Document,

No

tice of Start of Construction and

ot

her OSHPD FDD for

ms

and required docume

nt

s,

for

the facility known

as

_____________________

Facil

ity#

______

_

Date:

Signature:

N

ame

:

Title:

Address:

Phone:

City, State & Zip Code:

STATE OF CA

LI

FORNtA - HEALTH ANO

HU

MAN SE

RV

ICES AGE

NCY

OS

H·

FD-

XXX

·

TV

/MONI

TO

R BRACKET (

Re

v 08

/06/

14)

os

Dpd

- -

Clear Letter

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