HomeMy WebLinkAboutLA176083 �: •�,
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I�it[anufactured Home S�tstems Test Af�dawit
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'this form must be c4rnpieted in ifis entircty and be submitted at�e Building Fina!inspection for the instaHatian of a
manufactur�d horne. qii tests mast iae cvmpleEed and s�ned off on thi�fo�m. A certificat�cf occupancy wiil not be
issued untii this completed fomt!s received.
SYSTEMS 1'�ST V�RtFICATIQM
Description ��y~����� Daie Passed Signalure of Tester
Drajn Line: Pursuentta CFf�3260.692(b� pa�: �-I —�I — Z I ��v
Print N�ne af zester an�G�any: D c�n,�4-1 �j�.s�n,� �-�' �1 o bi( � �-�w� �w-A-Fw�..
Water Line: Pursuant to CFR 32811812(a) Da1e� — — 2��,_.._ ��� �
Print Neme aF 3eater end Company: ��� ► (� e.r-
Fixtu�e Test: Pursuanttq C�tt 3280,6'!2(a) Dare: y- 9 _Z �� v
^Print Name of"iasier and Ccmpany: J�,�� ���� � �S��-j��
C�88 TB�i#: Putsuant to CfR 3280.705 anc31FGC 4t�.4 Data. � ,,.� .� ".
Prin!Nsme af'Fester and Ce»np��y: � f�,.,l� �� � Ur-- ,�„�-� 1/� �..
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eracalcal ape�ationa�: �ursuant m cFR za�.7o2 �ate: � �� � �
Prini Name o#Tester and Camp�y,Z� �;�,��.�'�}Q�., � �, G` '-K°�•C �i �-���1 C..e�
EIBCtNCBi POIHTi1'�: Pwsuant to CFR 3285 7Q2 �e�:� ,1'
Prin1 Name ot Tester and ComPanY-�I u�� V '� 112.. �� .E G-tK��'c�"�. � �E��t�----���
GIQ{irill����At�nu�. �'��.�' nt�Q{^i�}'�.32�.�� ��Q; ,._�C� iL`��'7 wr. .
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Pnnt Name of Teater and Ganpany: � , �;,� �` 1+�-`. �t� .�,� ,�: [�y`�.�.,�,r' �
Srnoke Atarm Tes�:Pursua�rt m C��t s�eo.2oe Date: — -- 2-- ( �� -v�-
p�iai N�rrr�ot Teater anci Cc:mp�na���� �c . S
I�erti�fy the a�av�e syst�r►s test�ng has been completed and w aund fo be in camptlance w�f the Pro�na i�farst�ed inr eack►
eysEems Eest
i 4�at�e ,�j'`'r�� � �
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ELECTRICAL AFFIDAVIT
THIS CERTIFICATE MUST BE FILLED OUT COMPLETELY BY THE ELECTRICAL
CONTRACTOR AND FILED WITH THE ELECTRICAL UTILITY BEFORE ELECTRICAL SERVICE
CAN BE CONNECTED
Permit#: U4 � '
Job Site Address: � C y" r � � �
,_
a' r �, .r Y
Owner: � � �� � �"���`to.�..'� Cr42Cti�d �C._;
Electrical Contractor/Com an ►vame:Z.� �'-E �L'��-- ��-C����-
Contractor License# Master Electrician License#: �� � �'�.f.I`��-
Mailing Address �Contra Company or Owner Performina �nstallation):
Street Address �� � � � L
Cit ����t-L-'�`��'' State �� Zi Code ���� l�
Office Phone# �— �'�� ���� Contact Phone#: �I� - �CG-� - �y ��
Printed Name of Aut or�zed Individuai �� �v� •.��.-�'��
Authorized Signatu
�. 1�.
AMPERAGE SIZE ��'Wr
SERVICE ENTRANCE CONDUCTOR SIZE �' �-
THREE PHASE SINGLE PHASE �
DATE UTILITY CONNECTION IS REQUESTED ��aLt �c�- f
Lakeville Utility Providers:
Dakota Electric
Xcel Energy
2/28/2006