OFFICE OF STATEWIDE HEALTH PLANNING AND DEVELOPMENT FACILITIES DEVELOPMENT DIVISION “Access to Safe, Quality Healthcare Environments that Meet California’s Diverse and Dynamic Needs” STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY OSH-FD-700 (REV 1/24/13) Page 1 of 2 APPLICATION FOR OSHPD PREAPPROVAL OF MANUFACTURER’S CERTIFICATION (OPM) OFFICE USE ONLY APPLICATION #: OPM-0286-13 OSHPD Preapproval of Manufacturer’s Certification (OPM) Type: New Renewal Update to Pre-CBC 2013 OPA Number: Manufacturer Information Manufacturer: Milestone AV Technologies Manufacturer’s Technical Representative: Michael Harrell Mailing Address: 8401 Eagle Creek Parkway, Ste 700, Savage, MN. 55378 Telephone: (952) 225-6313 Email: [email protected] Product Information Product Name: MTMP1U Series Monitor Wall Mounts Product Type: Computer Product Model Number: MTMP1U General Description: Wall Mount for Video Monitor Applicant Information Applicant Company Name: EASE Co. Contact Person: Jonathan Roberson, S.E. Mailing Address: 5877 Pine Ave. Suite 210, Chino Hills, CA. 91709 Telephone: (909) 606-7622 Email: [email protected] I hereby agree to reimburse the Office of Statewide Health Planning and Development review fees in accordance with the California Administrative Code, 2013. Signature of Applicant: Date: 12/7/15 Title: Principal Engineer Company Name: EASE Co. 02/18/2016 OPM-0286-13: Reviewed for Code Compliance by William Staehlin Page 1 of 8 i d d d d d d e e e e o o o o o W W M a M a M o o i o ideo Mo d n M de n M W de M W e t o eo t o a o o o u a o o u a M r n l Monitor n M t Mo M t o s M o s M n n o i o t u to u o u or n r n t t s s M it nt s Emai Michael.h onitor W U for V il: ael.ha on U t Wa Vi or itor W ma il: Mic William William Staehlin Staehlin OPM-0286-13 02/18/2016
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OFFICE OF STATEWIDE HEALTH PLANNING AND DEVELOPMENT FACILITIES DEVELOPMENT DIVISION
“Access to Safe, Quality Healthcare Environments that Meet California’s Diverse and Dynamic Needs”
STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY OSH-FD-700 (REV 1/24/13) Page 1 of 2
APPLICATION FOR OSHPD PREAPPROVAL OF MANUFACTURER’S CERTIFICATION (OPM)
OFFICE USE ONLY
APPLICATION #: OPM-0286-13
OSHPD Preapproval of Manufacturer’s Certification (OPM)
Type: New Renewal Update to Pre-CBC 2013 OPA Number:
Manufacturer Information
Manufacturer: Milestone AV Technologies
Manufacturer’s Technical Representative: Michael Harrell
Mailing Address: 8401 Eagle Creek Parkway, Ste 700, Savage, MN. 55378
Telephone: (952) 225-6313 Email: [email protected]
Product Information
Product Name: MTMP1U Series Monitor Wall Mounts
Product Type: Computer
Product Model Number: MTMP1U
General Description: Wall Mount for Video Monitor
Applicant Information
Applicant Company Name: EASE Co.
Contact Person: Jonathan Roberson, S.E.
Mailing Address: 5877 Pine Ave. Suite 210, Chino Hills, CA. 91709
Telephone: (909) 606-7622 Email: [email protected] I hereby agree to reimburse the Office of Statewide Health Planning and Development review fees in accordance with the California Administrative Code, 2013.
Signature of Applicant: Date: 12/7/15
Title: Principal Engineer Company Name: EASE Co.
02/18/2016 OPM-0286-13: Reviewed for Code Compliance by William Staehlin Page 1 of 8
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OFFICE OF STATEWIDE HEALTH PLANNING AND DEVELOPMENT FACILITIES DEVELOPMENT DIVISION
“Access to Safe, Quality Healthcare Environments that Meet California’s Diverse and Dynamic Needs”
Registered Design Professional Preparing Engineering Recommendations
Company Name: EASE Co.
Name: Jonathan Roberson, S.E. California License Number: S4197
Mailing Address: 5877 Pine Ave. Suite 210, Chino Hills, CA. 91709
Telephone: 909-606-7667 Email: [email protected]
OSHPD Special Seismic Certification Preapproval (OSP)
Special Seismic Certification is preapproved under OSP- (Separate application for OSP is required)
Special Seismic Certification is not preapproved
Certification Method(s)
Testing in accordance with: ICC-ES AC156 FM 1950-10
Other* (Please Specify):
*Use of test criteria other than those adopted by the California Building Standards Code, 2013 (CBSC 2013) for component supports and attachments are not permitted. For distribution system, interior partition wall, and suspended ceiling seismic bracings, test criteria other than those adopted in the CBSC 2013 may be used when approved by OSHPD prior to testing.
Analysis
Experience Data
Combination of Testing, Analysis, and/or Experience Data (Please Specify):
List of Attachments Supporting the Manufacturer’s Certification
Test Report Drawings Calculations Manufacturer’s Catalog
Other(s) (Please Specify):
OFFICE USE ONLY – OSHPD APPROVAL VALID FOR CBC 2013 ONLY
Signature: Date: 02/18/2016
Print Name: William Staehlin
Title: SSE
Condition of Approval (if applicable):
STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY OSH-FD-700 (REV 1/24/13) Page 2 of 2
02/18/2016 OPM-0286-13: Reviewed for Code Compliance by William Staehlin Page 2 of 8
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