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Il�a�,uf�c#ura_„_,d H ,gr�e_�y�lems Test�ffid�vit
This form must be campfated;n its entirety and be subrnitted at the BuiWing F{n�l inspectian for the lnstalYatit�m af a
manufactur�ed home. All tests must be cx�mpleked and s�ned aff on this form. A certif'�cate of occupancy wili nat be
issued unt�l this completed fiarnn ls received.
SYSTEMS TE3T VERIPICATlON
Dascriplian Date Passed Signature af T�ster
Drain Une: Pursuanr tc CFR 328t).8i2{b) Date; _ � _ Z ��j"'�,,,c�
PriM Name of Tester and Compe�y: a.r��c�I S ►1 � � G ��a- ���
W�tBi"L111@: Pursuar�t to CFR 32�tt 61�(a) D�: - - Z q� � �
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Print Na+ne of Tester and Compeny: � M b �
� �� 6 1
Fixtui8l`BSt: Purauantto CFR 32�.812(c� Date: L� —� - 2� �� �
Print N�of Teater an�Carrtpany: " � , �- ,b� I�s- -���
Gas Tsst: Pun3udM to CFR 3280.7t)5 and I�fiiC 406.4 Dete: 3 _ ��..�
Prini Nams cf T�ter and Company: ,���� ��� „�,.N'y1(.,�..,�
EiectNcat Qpera#Iona1; �ursuant to e��t 2s�.�02 o�te- �` , ��, ,
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Prinf Name uf 7eatAr gnd Gc�rnparty �pf L+'•.�...�'t, 'i(,�L.- � �:C��r C... ,.
El�tCtr�C8) P418f1#y: Pwrsu�nt to CFR 3285.702 Date: "��''� y���-
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Pnnt Narr�e af Taetet artd CompBny: L f �;,�_ ���,,'v�2--� �. � '�
EleCtr�ca) Cottt�nuity: Pussuarrt to C�R 3285.7� Date:,"' � o� I ��
Print Name Qf Teater aod Camper�y: ,� �! i _ � ,�
3i17�k6 Alarnl T�t: Purauant to CFR 3280.2U8 �._ _�. Date:� --� _Z) rn�� �--
_... Df
Pr��t tvame c�Teatsr and c.atrr�any: ��L � � . �- � i G r�. `�
R cert�fy tne abovs systems testin�h�s h�an camp�ted and wes i �o be in cx�mpiie�e w�h the provisbns i�entibed�r eaah
sy�te�rns test:
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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#: l.�' +� fJ �� �
y �� ��
Job Site Address: � ��r 1 f ( �'�� "�—
. � � _J�,,
Owner. � � ��� `. '� � ' '�'� C.�L(:LJ�e�r �
1 ` � �� "�._ C �.�c.-}�� : ti� �'���� ��-
Electrical ContractoNCom an Name:�--�� ""`
Contractor License# CA Master Electrician License#: � L C CLl 1^�
Mailing Address �Contracter. pany or Owner Performing Insta lation)
Street Address � • � � �-=r
� � ; �� �� �C'
Cit � t� *t� � State '�')j�L, Zip Code i ?r ~
� � : 1 � � �. .
Office Phone# '/ � � �i� y; � �L�' Contact Phone#: �! " �.� � `�
� i � .,�'
Printed Name of Authonzed Indivi I: �
Authorized Signature: --
� ^
AMPERAGE SIZE �,�'��� - �
SERVICE ENTRANCE CONDUCTOR SIZE Fr��,;;��
THREE PHASE SINGLE PHASE �_
DATE UTIUTY CONNECTION IS REC2UESTED ����f: �-�
Lakeville Utility Providers:
Dakota Electric
Xcel Energy
2/28/2006