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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���Lf�p ��.r,,,�,)
Print Name of Tester and Company: ���_ �,� ��rr �C��
Water Line: Pursuant to CFR 3280.612(a) Date:��- ��p �� ��tx✓
Print Name of Tester and Company:
FIXtU�@ T@St: Pursuant to CFR 3280.612(c) Date:�� �- y/�,�' D� �-^�,
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Print Name of Tester and Company:
GeS TeSt: Pursuant to CFR 3280.705 and IFGC 406.4 Date: �c � G� �C��
Print Name of Tester and Company: 'j:�l 2 r /'����..e r- M��;,�� (..�,;^�Z 5�' �v',��-- �--
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Electrical Operational: Pursuant to cFR s2ss.�o2 �ate: �—�3—�
Print Name of Tester and Company:s-t-,.�� ��� ���d G�� �� ����
Electrical Polarity: Pursuant to CFR 3285.702 Date: � _ ��2�
Print Name of Tester and Company: �
Electrical Continuity: Pursuant to CFR 3285.702 Date: � �-�� —�
Print Name of Tester and Company: �tr i
Smoke Alarm Test: Pursuant to CFR 3280.208 �ate: �_�3���
Print Name of Tester and Company: �i
I certify the above systems testing has been completed and was found to be in compliance with the provisions identified or each
systems test:
Si nature: � Date:/ �`�� ��