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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 instaltation of a
manufactured hame. A(1 tests must be completed and signed aff on this form. A certificate of occupancy will not be
issued until this completed form is received.
SYSTEMS TEST YERIFICATION
Description Date Passed Signature of Tester
DPa111 Lir1e: Pursuant to CFR 3280.612(b) Date: C �.z'�� ,�� ��� /�,�
Print Name of Tester and Company: e-�'�'" `S' � �_ ��
Water Line: Pursuant ta GFR 3280.612(a) Date: ���� � �� /���
Print Name of Tester and Company:
Fixture Test: Pursuan4 to CFR 3280.612(c) Date: y .�`7—�„� ��
P►int Name of Tester and Company:
Gas Test: Pursuant to CFR 3280.705 and IFGC 406.4 Date: �� 3,� , 1 ( '�-a--, ��
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Print Name of Tester and Company: ���fy, ��� �� /�y �,��5,,��t �� ��`�� i v'�
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Electricai Operationai: Pursuant to CFR 3285.702 Date: �!�;�.�,��
Print Name of Tester and Company:�.��„ ������ ��.C,,t �j
EI@C'tt'IC81 P0181"Ity: Pursuant to CFR 3285.702 Date: �_�-.�`�,�..t
Print Name of Tester and Gompany: ��� �,� �
Electrical Continuity; pursuant to CFR 3285.702 Date: ��._�.. ���.(
Print Name of Tester ar►d Company: j� �
SI110ke AIaPI'1'1 T@St: Purswant to CFR 3280.208 Date:G�,.� ��� ,,2 �
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 identifie or each
systems test:
Si nature: ��
Date: �� �' �