OSHPD PREAPPROVAL OF MANUFACTURER'S CERTIFICATION … · 05/11/2017 OPM-0421-13: Reviewed for Code...
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“Access to Safe, Quality Healthcare Environments that Meet California’s Diverse and Dynamic Needs” OFFICE OF STATEWIDE HEALTH PLANNING AND DEVELOPMENT FACILITIES DEVELOPMENT DIVISION STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY OSH-FD-700 (REV 12/16/15) Page 1 of 2 APPLICATION FOR OSHPD PREAPPROVAL OF MANUFACTURER’S CERTIFICATION (OPM) OFFICE USE ONLY APPLICATION #: OPM-0421-13 OSHPD Preapproval of Manufacturer’s Certification (OPM) Type: New Renewal Update to Pre-CBC 2013 OPA Number: Manufacturer Information Manufacturer: MEDIVATORS Manufacturer’s Technical Representative: Megan Dickey Mailing Address: 14605 28 th Avenue N., Minneapolis, MN. 55447 Telephone: On File Email: On File Product Information Product Name: Advantage Plus Product Type: Other mechanical and electrical components Product Model Number: N/A General Description: Endoscope Reprocessing System 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, 2016. Signature of Applicant: Date: 4/11/17 Title: Principal Engineer Company Name: EASE Co. r r o ro e o e o e c c l c c e e e e e e c c t r e r e e c e c e pr a e r a a c ro c o oc c t ce S S c r ce S S o r es o c m c m c m a i a t p l p p c o c o n o n o E S n o E S e m e m m n m m m n m m t p a a t t p a t s o i s o l : n n E e E e E m n m n m O t m O s a s a a : O O trical components trical components ssing System ssing System apolis, MN. 55447 Email: On File al and e Rep a e eapolis, MN. 55447 a pe Email: On e pr an and O File e Re Jeffrey Y. Kikumoto OPM-0421-13 05/11/2017 // 05/11/2017 OPM-0421-13: Reviewed for Code Compliance by Jeffrey Kikumoto Page 1 of 10
Transcript of OSHPD PREAPPROVAL OF MANUFACTURER'S CERTIFICATION … · 05/11/2017 OPM-0421-13: Reviewed for Code...
“Access to Safe, Quality Healthcare Environments that Meet California’s Diverse and Dynamic Needs”
OFFICE OF STATEWIDE HEALTH PLANNING AND DEVELOPMENTFACILITIES DEVELOPMENT DIVISION
STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCYOSH-FD-700 (REV 12/16/15) Page 1 of 2
APPLICATION FOR OSHPD PREAPPROVAL OF MANUFACTURER’S CERTIFICATION (OPM)
OFFICE USE ONLY
APPLICATION #: OPM-0421-13
OSHPD Preapproval of Manufacturer’s Certification (OPM)
Type: New Renewal Update to Pre-CBC 2013 OPA Number:
Manufacturer Information
Manufacturer: MEDIVATORS
Manufacturer’s Technical Representative: Megan Dickey
Mailing Address: 14605 28th Avenue N., Minneapolis, MN. 55447
Telephone: On File Email: On File
Product Information
Product Name: Advantage Plus
Product Type: Other mechanical and electrical components
Product Model Number: N/A
General Description: Endoscope Reprocessing System
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, 2016.
Signature of Applicant: Date: 4/11/17
Title: Principal Engineer Company Name: EASE Co.
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Jeffrey Y. Kikumoto
OPM-0421-13
05/11/2017/ /
05/11/2017 OPM-0421-13: Reviewed for Code Compliance by Jeffrey Kikumoto Page 1 of 10
“Access to Safe, Quality Healthcare Environments that Meet California’s Diverse and Dynamic Needs”
OFFICE OF STATEWIDE HEALTH PLANNING AND DEVELOPMENTFACILITIES DEVELOPMENT DIVISION
STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCYOSH-FD-700 (REV 12/16/15) Page 2 of 2
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: 909-606-7622 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 1950-16
Other* (Please Specify):
*Use of criteria other than those adopted by the California Building Standards Code, 2016 (CBSC 2016) 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 2016 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 2016 & ALL PRE-2016 CODE BASED PROJECTS
Signature: Date: 05-11-2017
Print Name: Jeffrey Kikumoto
Title: SSE
Condition of Approval (if applicable):
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