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Manufactured Home Svstems Test Affidavit
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
issued until this completed form is received. ����
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SYSTEMS TEST VERIFICATION
Description Date Passed Sig re of Tester
Drain Line: Pursuant to CFR 3280.612 (b) Date:� � �oa�
Print Name of Tester and Company �, ,, � �
Wet@r L111@: Pursuant to CFR 3280.612 (a) Date� ���aG
Print Name of Tester and Compan . � �
,
FlXtut'e TeSt: Pursuant to CFR 3280.612 (c) Date:� �o"��'�
Print Name of Tester and Company� �„ � ?
GaS TeSt: Pursuant to CFR 3280.705 and IFGC 406.4 Date:
Print Name of Tester and Company:
Electrical Operational: Pursuant to CFR 3285.702 Date:
Print Name of Tester and Company:
Electrical Polarity: Pursuant to cFR 32s5.�o2 Date:
Print Name of Tester and Company:
Electrical Continuity: Pursuant to CFR 3285.702 Date:
Print Name of Tester and Company:
Stl10k@ Alal'1'Y1 T@St: Pursuant to CFR 3280.208 Date:
Print Name of Tester and Company:
I certify the above systems t g has been completed and was found to be in compliance with the provisions identified for each
systems test:
Si nature: � � Date: � V ���
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Manufactured Home Svstems Test Affidavit
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
issued until this completed form is received.
- -__������ �'
SYSTEMS TEST VERIFICATION
Description Date Passed Signature of Tester �
D�8111 L111@: Pursuant to CFR 3280.612 (b) � Date:
Print Name of Tester and Company:
W8t@I' L111@: Pursuant to CFR 3280.612(a) Date: ;
Print Name of Tester and Company: �
FIXtU1'e TeSt: Pursuant to CFR 3280.612(c) I Date:
Print Name of Tester and Company:
G83 TeSt: Pursuant to CFR 3280.705 and IFGC 406.4 Date: LJ�- �,� -
Print Name of Tester and Company: � �:Z �1S' �!�'�� ��/ �f/V�
Electrical Operational: Pursuant to CFR 3 85.702 Date:
Print Name of Tester and Company:
ElectriCal Polarity: Pursuant to CFR 3285.702 Date:
Print Name of Tester and Company:
EI@Ctl'IC81 C011t111U1t�l: Pursuant to CFR 3285.702 Date:
Print Name of Tester and Company:
Smoke Alarm Test: Pursuant co CFR 32so2oa oate:
Print Name of Tester and Company:
I certify the above systems testing has been completed and was found to be in compliance with the provisions identified for each
systems test:
Si nature: � Date: `� �� ' ` �
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