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HomeMy WebLinkAboutUntitled U CERTIFICATION FORM FOR CLINICS AND FREESTANDING OUTPATIENT CLINIC SERVICES OF A HOSPITAL I certify that the following facility conforms to current applicable edition of the California Building Standards Code* and as such meets the applicable clinic standards (OSHPD 3) propounded by the Office of Statewide Health Planning and Development. Facility ti.k VITA DIALsvc5 GLIA►�tC; Street Address 721 WI - 1- t,67 City } t)i. iCA - 71007 Type of Facility 1S. Chronic Dialysis Clinic (see note 1) ❑ Surgical Clinic (see note 1) ❑ Rehabilitation Clinic ❑ Primary Care Clinic El Birthing Clinic ❑ Psychology Clinic ❑ Out Patient Clinic Service of a Hospital Service(s): Name SItzfq-i/144 Title (3Uit,i�r O cicrock. Street Address City AeCitipiii CA- , ?/007 Signature 541( Date g.2- ,ref `2009 IBC and 2010 California Amendments (10 California Building Code—Part 2, Title 24, CCR) 2008 NEC and 2010 California Amendments (10 California Electrical Code— Part 3, Title 24, CCR) 2009 UMC and 2010 California Amendments (10 California Mechanical Code— Part 4, Title 24, CCR) 2009 UPC and 2010 California Amendments (10 California Plumbing Code— Part 5, Title 24, CCR) 2009 IFC and 2010 California Amendments (10 California Fire Code—Part 9, Title 24, CCR) Also see attached amended CAN 1. Note 1: Per Health and Safety Code § 129885 certification of chronic dialysis and surgical services are required to be provided by city or county building department with jurisdiction over the project. If the building jurisdiction will not be providing this certification, plans shall be submitted to OSHPD for certification review. ;;, e; 3