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�nu�c�ured Hc�me S}�„s�em� Test Aff�ciavit
i his fQ�m rnust�campleted in its er►t�rety and be subrt►�tted at the�uildir►g�ina1 iz�spectian for the irystaliation of a
nanuf�actured hame. Atl tests must be c�mpteted and sigri�c#off on this form. A cecE�fc�te of occupancy witi not be
ssued until this cc�rr�pletec!form is rece�ed.
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SYSTEMS fiEST YERI��CATfiON
D�.scrip�ion Q�#e Pas:�ed Si�nature c�f T�st�r
3�"ain�it'�: Pur�sant ta C�R 3280,612(b} t?�te;
'rint Natrte of 1'e�'anci Corn�art�r:
�118�t 1.1�: Furst�r�ta CFR 3280.�92{a} C'�ate:
't�t N af Tes�er ar�d C�any:
FiX�t�+B T� P�artt ta C�R 3280.612{c} Date:
�rint IV�of Test+er ar�d Company:
�S T++B� purst�t to CFR 328t3.705 and IFGC 406.4 [1ate: �j -� �.-
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�rin#N�rr�af Tes�r and CaYnpr��ty: ���' ��t�� ��C`�i.�' ��3}�}��J��.
E!@C�CS1 QpBlA1i0�1; Pu�°suanf to GFR 3285.7{32 Date:
'ti�[+�r1e of TBster at�d Cc�nparty:
;I�Ctt�C�l PC��!`1t�/: Pursu�nt to GFR 3285.702 �:
�rint l�arnt�of�'�ter�d Company:
:113Ctt'iC�t Ct�li�ittUily: Pursuant to CFR 32$5.702 Dat�:
'rir�t Na�r�e�Testar�rd ny:
imok+�A�rm T� Purs�t to cF�:�2so2t�s t�t�:
'rirrt c>f T ��Cc,�rtparty:
t�iiy thae sy�errts�stit�h�s�c�pteted a�w�fixtnd#o be in c�r�' u�ith� ' �ons�tifi�ect�r'e�h
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