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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
Drain Line: Pursuant to CFR 3280.612(b) Date:��` _,_�D P�j ��
Print Name of Tester and Company: e � �� J
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W8te1' LI11@: Pursuant to CFR 3280.612(a) Date: ,,.7 .Z� �� /�
Print Name of Tester and Company:
FIXtIIC@ TeSt: Pursuant to CFR 3280.612(c) Date:��_ -7 �. �� �� /�
Print Name of Tester and Company:
GaS T@St: Pursuant to CFR 3280.705 and IFGC 406.4 Date: ��? _���y '��;
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Print Name of Tester and Company: ��,���� - �1����,�t�.�f �.;,��(% S�r �i L�
EIeCtCICaI Op@C1t1011a1: Pursuant to CFR 3285.702 Date: �?-- ,_j j - ,��'i ' ��,
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Print Name of Tester and Company: ����-✓�� ��' ✓ �'�:� �'�r��
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Electrical Polarity: Pursuant to CFR 3285.702 Date: �- ,�. 7 ,�G; �
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Print Name of Tester and C o m p a n y: ' /'. ��� f��
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Electrical Continuity: Pursuant to CFR 3285.702 Date: �_ ,� �• �`;� "
Print Name of Tester and Com an f
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Smoke Alarm Test: Pursuant to cFR 32so.2os Date: '�' - � ,� - �L/ �
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Print Name of Tester and Company:
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I certify the above systems testing has been completed and was found to be in compliance with the provisions identified�for each
systems test:
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Si nature: Date: � �