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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�altl L111@: Pursuant to CFR 3280.612(b) Date:f�.. �� _1 ., �- /��
Print Name of Tester and Company: _ ��, l
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Water Line: Pursuant to CFR 3280.612(a) Date: ��_ � ��� n�� /��
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Print Name of Tester and Company:
FIXtU1'@ T@St: Pursuant to CFR 3280.612(c) Date: /, - ��-��*l �
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Print Name of Tester and Company:
Gas TeSt: Pursuant to CFR 3280.705 and IFGC 406.4 Date: I�•-�j�� �, v
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Print Name of Tester and Company: ����N _ ��5-�-�t l�'�p b. �-�. �,(-�c�„e S�r�� �-
EI@Ct�IC81 Op@I'at1011a1: Pursuant to CFR 3285.702 Date: �r'�-UZ��Z Q
Print Name of Tester and Company: �j;��L„� �'__�.. l
EI@Ctl'ICaI POIaPIty: Pursuant to CFR 3285.702 Date: � -��•��
Print Name of Tester and Company: �` ' � �����
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Electrical Continuity: Pursuant to CFR 3285.702 Date: 7 -� � �O _ _
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Print Name of Tester and Company: �`� �if��
Smoke Alarm Test: Pursuant to CFR 3280.208 Date:
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Print Name of Tester and Company: �/VJ�(J� - �,� ��,L G
I certify the above systems testing has been completed and was found to be in compliance with the provisions identified for ach
systems test:
Si nature: Date: /Z / �" ��