OFFICE OF STATEWIDE HEALTH PLANNING AND DEVELOPMENTFACILITIES DEVELOPMENT DIVISION

“Access to Safe, Quality Healthcare Environments that Meet California’s Diverse and Dynamic Needs”

STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCYOSH-FD-700 (REV 1/24/13) Page 1 of 2

APPLICATION FOR OSHPD PREAPPROVAL OF MANUFACTURER’S CERTIFICATION (OPM)

OFFICE USE ONLY

APPLICATION #: OPM-0362-13

OSHPD Preapproval of Manufacturer’s Certification (OPM)

Type: New Renewal Update to Pre-CBC 2013 OPA Number:

Manufacturer Information

Manufacturer: PEERLESS INDUSTRIES, INC.

Manufacturer’s Technical Representative: Mark Berens

Mailing Address: 2300 White Oak Circle, Aurora, IL. 60502

Telephone: On File Email: On File

Product Information

Product Name: Articulating Wall Mount 10” to 50” Monitors

Product Type: Cantilever

Product Model Number: SA730P, SA740P and SA746PU

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: J.Roberson@EASECo.comI 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: 6/22/16

Title: Principal Engineer Company Name: EASE Co.

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OPM-0362-13

09/19/2016

09/19/2016 OPM-0362-13: Reviewed for Code Compliance by William Staehlin Page 1 of 8

OFFICE OF STATEWIDE HEALTH PLANNING AND DEVELOPMENTFACILITIES 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: 909-606-7622 Email: J.Roberson@EASECo.com

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: 09-19-2016

Print Name: William Staehlin

Title: SSE

Condition of Approval (if applicable):

STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCYOSH-FD-700 (REV 1/24/13) Page 2 of 2

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