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Manufactured Home �ystems Test Affedavit
This form must be completed in its entirety and t�e subrnitted at the Building Final inspectic��for the instai{�tian af a
manufactured home. Alk tests must be completed and signed off on this form. A cerEificate of occupancy will na��-=e
issued until th;s completed farm is recefived. ����/ �__ _ _ /�� /��;,� 'n , , n l��
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SY�T�M� TES�" 10�#�IFI�ATIQ�!
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Description Date Passed iigF�ature of Tester !
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Drain Line: Pursuant to CFR 3280.6�2 (�) Date ;
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Print Name af T�ster ar�d Company: �� �
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Water Line: �ursuant to CFR 32$o.s�z (a> ' raace: '
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Print Name of Tester and Company: �
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F(XtUM'@ T�St Pursuant ta CFR 3280.612 (c} Date
Print Name of Tester and Company: �
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G8S TeSt. PursGant tn CFR 3280 705 and IFGC 406.4 I Date. ��1� � ' -- —�
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Print NamE af Tester and Cnmpany: � �l���.... ��� �'�a��t �,Q �„j��: ����(..;�_ �
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Electric�l Operational: Pursuant to CF 3285.702 � Date:
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Print Name of Tester and Gompany: I ;
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E1eCt1'lCc�l Pol�!"Itjl: Pursuant to CFR 3285 7fi2 �Date: r ;
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Print Name of Tester and Company � �
Eiectricai�Cnnt�nuity��Pursuant to��m ����. �_�_ .._ . -,.�,.�w��,�r_� ����,.���.��-� �
CFR 3285.702 �Date: � ;
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Print Name of iester and Company: i f
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Srt'10kG AI81'1't't T�St: Pursuant to CFR 328Q208 i Date: i
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Print Name of Tesier and Company: '
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i czRify the above systems testing has been campl�ted and was f�unc�to be in compliance witi�the pravisionr,id�niifi�d for c:a�h '
systems test: +
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Manufactured Home Svstems Test Affidavit
Ttiis form must be completed in its entirety and be submitted at the Building Final inspection for�he ins���l�ation c�F�
manufactured home. All tests must be tompleted and signed aff on this form. A certificate of occupancy will rat b�
issued unti{this campleted form is received.
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SYSTEMS TEST VERIFICATIOh]
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�� Description � Date Pass�d �ignat�.�r� c�f Test�r �
; �t'�in L'tt18: Pursuant to CFR 3280.612(b) i Date: ��� ���
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' Print Name af Tester and Company: i
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' Wat@f Lltl@: Pursuant to CFR 3280.6'i2(a} i Date: �
; Print Name of Tester and Company: }
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FixtUt'e T�St: Pursuant to CFR 3280.612 (c) G Date: ;
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Print Name of Tester and Cornpany:
I GaS TeSt: Pursuanf to CFR 3280.705 and IFGC 4d6.4 date:
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� P�int Narne of Tesler and Cornpany:
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Electrical Operational: Pursuanc to CFR 3285.702 oate: � ' �
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Print Name of Tester and Company: � ! �,Q �1�� C� {,,��,���„{� � _
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;, Electrica) Polarity: Pursuant to CFR 3285.702 � Qate: (.�t ' ��G„��� N
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j Pr�nt Name c�i Tester and Gornpany: �� �� ���1r� �° " � i �^�---
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� Electrical Continuity: Pursuant to c�R 32e5.�o2 j oate � 1��� `
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; Print Nams of 7ester and Company: �� �,,� ���� �� � ��,� �
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� Smoke Alarm Test: Pursuanx to CFR 3280.208 ; Date:
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; I�rint Name of Tester and Company:
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� I certify th above systems testing has been completed and was found to be in compfiance with the provisions identified(ar e��h
j systems t t
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Date:
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Manufactured Home S stems Test Rffidavit
This form must be completed in its entirety and be submitted at the Building Final inspection for the installation of a
manufactured home. All tests must be completed and signed off on this form. A certificate of occupancy will not be f
issued until this completed form is received.
-- ------ �:
__._._._ _______ _ SYSTEMS TEST VERIFICATION
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Description Date Passed �
-- =-__---- Sign�t re of Tester
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