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 Finalissued 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
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
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-
max
1
1
254
C
E
lC)
X
co
....
E
co
(")
CX)
"'-l"
FIGURE
11B-308.3
.1
UNOBSTRUCTED
SIDE
REACH
m
..-
N
,-
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.
-8-
2X
wood
l
st1.1dls
~
or
2x
sdltdl woodl
b
!f
ocki
ll
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Mtll.
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Compliance
Yes No NA
For anchor locations not coinciding with existing wood studs, blocking to be
added as shown below
2x wood stud
4x or 6xwood
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
Sc
rew Pattern
M
ax
i
mum
Arm Extensi
on
(inches)
3 6 9
12
15
18
M
ax.
TV
We
ight
(l
bs) 150 110 80 65
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
4x
or6x
wood
l hlockirng1
at
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of
wa
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at
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ve
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e
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bs.
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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
ew
Spa
cing = 6 inches
Arm E
xt
ension (in
ch
es
)
Num
be
r of Screws 3 6 9 12 15 18
2
90
65
50 40 30
25
I
3 100 100 100
85
75
60
4 or More 100 100 100 100 100 100
j
Max
i
mum
arm extemion
must
allow
for
free
181J
0
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
ICE
OF
STATEWIDE HEALTH PLANNING AND DEVELOPMENT
FA
CILI
TI
ES DEVELOPMENT DIVISION
Application for New Project/Bu
il
ding Permit
F
ac
ili
ty
F
ac
ili
ty#
________
Facility
Name
OSH
PD Buildi
ng#
BLD - Building N
ame
T
ype
of
Facility
IEJ
Skilled Nur
si
ng
or
lntennedi
ate
care Facility
Record
Detail
I Proje
ct#
Reco
rd/P
ro
ject
Name
WALL
MO
UN
TE
D
TE
LE
VlSIO
JIII
M
ON
I
TO
R
BRACKE
T I
NS
TALLA
TI
ON
De
tail
ed
Desc
ri
ption
App
li
cat
i
on
Spec
ific
Info
r
mat
i
on
SU
b
mitt
at
T
ype
IE] Final
Kl
nd of Project IE] R
emode
l/
Al
t
era
ti
on
U
se
An
nual
Bu
ildi
ng
P.enn
it O
Yes
O
No
Contact
I
nformation
0
Primary
T
ype
Le
gal Owner I Administrator (R
e<J
u;,
ed
t
or
au
applic
3'ionsl
Rrst
Name
.
____________
.M
.I
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Las
t N
ame
______
_
OFFtCE USE
ON
LY
RE
CEIVED
Or
ganiza
tion
Name
------------------------------------
Str
eet
Ad
dr
ess
-------------------------------------
Add
re
ss
Line2
-------------------------------------
City:
________________
&ate.
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~
np
Code
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ho
ne.
_____________
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ax
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Signa
tu
re
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il
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~~~~~~~~~
--
0 Primary T
ype
Authorized Agent
(A
uthorization m
us
t be attache
d}
Rrst
Name
.
____________
.M
.1
._
Las
t N
ame
Or
ganiza
tion
Name
------------------------------------
Str
eet
Ad
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ess
-------------------------------------
Add
re
ss
Line2
-------------------------------------
City:
________________
&ate.
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np
Code
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_____________
Phone2a
____________
,F
ax
___________
_
Signa
tu
re
__
~~~~~~~~~=
=-
-----
Da
te.
______
Ema
il - ~
~~~~
==
:::::;:--
--
STATE OF CALIF
OR
NIA - HE
AL
TH ANO HU
MA
N
SERV
ICES AGENCY
OS
H-F
O-
XXX
-
TV
/
MON
ITO
R B
RA
CK
ET
(Rev
08/
06
11
4)
osDpd
- 12 -
Clear Building Permit
,~
OFFICE
OF
STATEWIDE
HEALTH
PLANNING
AND
DE
VELOPMENT
FACILITIES
.:l,j
;i~
DEVELOPMENT
DIVISION
Const
ru
ct
i
on
Pe
rform
ed
By (che
ck
o!}!)
D Licensed Contractor
State of
ca
rrfo
mia
Contractol's
License
Nu
mbe
r
_______
Cl
ass
~
______
Exp
i
ratio
n Date
________
_
Rrst
Name.
_____________
M
.1
..
___
Las
t
Name
______
_
Or
ganiza
tion
N
ame
Street
Add
r
ess
Address
Line
2
C
fy
________________
Sla~
~
-----
-~p
Code
___
_
P
ho
ne
_____________
Phone
2.
____________
F
ax
CALI
F
OR
NIA
LIC
ENSED
CO
NTRA
CTOR
'S
DE
CLARATION
I her
eb
y
affirm
under penalty of
pe
rj
u
ry
that I
am
li
censed
un
de
r
~vis
i
ons
of
Chap
ter 9 (
comme
nci
ng
witll
Sec
ti
on
7000
) of Di
vi
sio
n 3
of
th
e
Busi
n
ess
and
Pro
f
essions
Code
, and my li
cense
is in
fu
ll
fcrce
and effect
Contracto
r or
Aut
h
Olized
Age
nt's
Name
___________________
_
Sig
n
atu
re~
___________________
Da
te
D Owner/Builder
OW
NER-
BU
ILD
ER
DE
CLARATION
I her
eby
affirm
under penalty of
perj
u
ry
that I
am
ex
elll)
t
from
the
Co
n
tractors
Sta~
License
Law
fo
r
the
fo
ll
owi
ng
reason
(s) in
di~
below
by the ch
ed<mark
(s) I
ha
ve
pl
aced
next
to
th
e
app
li
cable
rt
ems
(s)
be
l
ow:
(
Sec
. 7031.5, Busin
ess
and P
rofes,;io
ns
Code
:
An
y
city or
cou
nty
tha
t r
eq
ui
res
a
perm
it to
cons
tru
ct
, alter. i
mp
r
ove
,
demo
~sh or repair any st
ru
cture
,
prio
r to i
ts
issua
n
ce
,
also
re
quir
es
the
appl
icant
fo
r
the
perm
it
to
fi
le a sign
ed
st
~en
t
tha
t
he/s
he is li
ce
n
sed
pu
rs
u
an
t to the provisions of
th
e
Con
tractor,
Sta
te
Lice
nse
Law
(Ch
apter
9 (
commen
ci
ng
wi
th Section
7000
) of Di
visi
on
3 of the
Busi
n
ess
and
Professions
Code
) or that h
e/she
is ex
emp
t
from
li
cens
u
re
and
th
e
basis
fo
r the
alleged
ex
emptio
n.
Any
vi
olation
of
Section
703
1.5 by any
app
li
ca
nt
fo
r a
perm
it su
bjects
the
app
li
can
t
to a civil
pe
n
alty
of not
mo
re
tha
n
fi
ve hu
ndred
do
l
la
rs
(
$500
).).
Pl
ease
ch
eck
an
th
at
aonlv
fo
r the
to
11
0
Yt1
ng
:
D I, as
owne
r of
the
property, or my
emp
l
oyees
wi
th
wages
as
th
ei
r sole
compensa
ti
on.
wi
ll
do
th
e
v.:>
rk
,
and
th
e
structu
re is
no
t
int
ended
or off
ered
for sale (
Section
7044
,
Busi
n
ess
and
Pro
f
essions
Code
: The
Con
t
ractors
St~
Li
ce
n
se
Law
d
oes
not
app
ly to
an
owner
of property
Wh
o,
th
r
oug
h
emplo
y
ees
'
or
pe
r
so
n
al
effo
rt
,
bu
ilds or i
mproves
th
e
property
,
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
{
Re
v
08/
06
11
4)
o s
Dpd
- 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 Agenton
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
FD-
XXX
·
TV
/MONI
TO
R BRACKET (
Re
v 08
/06/
14)
os
Dpd
- -
Clear Letter