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Manufactured Hame Svstems Test Affidavit
This form must be completed in its entirety and be submitted at the 8uiiding Finai inspectian for the insta(lation of a
manufactured home. All tests must be completed and signed off on this farm. A certificate of occupancy wN!nat be
issued unt+l this completed form is received. `,,:,�� ) O ����° � '
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SYSTEMS TEST VERlFICATiI"3N
Description Date Passed Signature of Tester
Drain Line: Pursuantto CFR 32�o.s�2 t�� ��t�; �.��� _�a� }
Prini hiame of Tester and Company• ''�`'`��t tti�'t,��tr, /,;u��la��� (4,1�,-�,�,�;��7 �,.s.� ��y�r�
Wat�Et'LIriB: Pursuantto CFR 3280.612{a} �ate: C_�/_a�,f�
Print Name ofTester and Company. 4'c,,Y �{v.�il4ria, Iti;d ��1 t�tt-rJ ��i:.i tt'1�c�ltuy ���'i l��
�IxtUl"L T�S�: Pursuant ko CFR 3280.612{c) Date: j -�t-�a 6 � ,/�
Prin#Name af Tester and Campany: �`; ��� ��r-�'
L�y �(4'.;u1t�1'!U � ��1k��+:�!�l1Q L�t-�t'1�F'aL.�i1�.c� � ��
G�S TeSt: Pursuant fo CFR 3284.705 and 1FGC 406.4 Date:
Print Name of Tester and Company;
Etectricai t�peratianai: �ursuant ta c��32ss.7o2 s �ate:
Print Name of Tester and Campany:
J EI�Ctt`iCa! P0181'ity: Pursuant to CFR 3285.702 aate:
Prini Name of Tester and Company:
Ei�Ctric�4 Coriti�tuity: Pursuant to GFR 3285.7�2 Date:
Print Name af Tester and Company:
Smoke Aiarm Test: Pursuanc to cFR 32sa2os � �ate:
Print Name of Tester and Company:
i certify the above sys#ems testing has been compieted and was found to be in corrrpiiance with the provisions idenii�ed for each
systems test:
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Si nature:
Date: �`�� "�(' 6
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Manufactured Home Svstems Test Affida�v'�t,
7his form must be completed in its entirety and be�ubmitted at the Building Finai inspection#or the installation of a
rnanufactured home, All tests must be compieted and signed off on this form. A certi�cate of occupancy will not be
issued unti!this completed forrn is received. j---��/ „ �� � l r����1,,1 � / ���
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SYSTEMS TEST YERIFICATt4N
Description Date Passed Signature of Tester
Drain i.ine: Pursuant to c�R 3280.s�2��) �ate:
Prinf Name of iester and Company:
Water Line: Pursuant to CFR 3280.612(a) Date:
Print Name of Tester and Gompany:
FIXtUi'e T@St: Pursuant to CFR 32$0.612(c) Qate:
Print Name af 7ester and Company:
G8S TeSt: PursuaM#o CFR 3280.705 and iFGG 446.4 Date:�_�_ ':��,����„
Print Name of Tester and Company: ��- �G��S�` �/U,�''FC..��0�0 YJ! � .
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Efectricai Operationai: pursuant ta cF 32$s.7o2 �ate:
Print Name of Tester and Company: '
EteCU'iC1) POlel'ity: Pursuant to GFR 3285.702 Date:
Print Name of Tester and Company:
ElectriCal Continuity: Pursuant to CFR 3285.702 Date.
Print Name of Tester and Company:
Smoke Alarm Test: Pursuant to CFR 3280.208 Date:
Print Name of 7'ester and Company:
!certify the above systems testing has been compteted and was found to be in compliance with the provisions identified for each
systems test:
i nature: � ._.._`_ �, ... Date: � �� � �