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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 instailation af a
manufactured home. A!i tests must be completed and signed off an this farm. A certificate of occupancy wiil not be
issued until this completed form is received. ,
SYSTEMS TEST VERIFICQTION
Description Date Passed Signature of Tester
Drain Line: Pursuant to CFR 3280.612(b) Date: ���-- � ' �
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Print Name ofi Tester and Company: ,��-��, Q� , � � _ ��
WatBP Llil@: Pursu2nt to CFR 3280.612(a) Date: L ��— �
Print Name of Tester and Company:
Fixture Test: Pursuant to CFR 3280.612(c) Date:L!��'� 2/
Print Name of 7ester and Gompany: ��/�'�"�
GaS TeSt: Pursuant to CFR 3280.705 and IFGC 406.4 Date: �,,m '3,,� , 1� � '`�, �
Print Name of Tester and Company: F ��
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Efectricai Operational: Pursuant to CFR 3285.702 Date:��cl_�r
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Print Name of Tester and Campany: �-�—����,,1�4� y1.l��G�,� �C
Elec#rical Polarity: Pu►suant to cFR s2s5.7o2 �ate: ���_� �
Print Name of Tester and Gompany: , � �-(
Electrical Continuity: Pursuar�to CFR 3285.702 Date: Lj�...C� _�
Print Name of Tester and Company: c � r < �
St110k@ AIaP111 T@St: Pursuant to CFR 3280.208 Date: .���,-�>
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
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