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Manufactured Home Svstems Test Affidavit
This form must be completed in its entirety and be submitted at the Buifding Final inspection for the instailatian of a
manufactured home. All tests must be completed and signed off on this form. A eertificate of occupancy will not be
issued unti!this compieted form is received.
SYSTEMS TEST VERlFICATION
Description Date Passed 5ignature of Tester
Dt'�i17 Lir1@: Pursuant to GFR 3280.612{b) Date: 4/_ . _�t J�`'��
Print Name of Tester and Company: z�'c r 1�S ��
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Water Line: Pursuant to CFR 3280.612(a) Date: � 7 ,� 1 /�� ��
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Print Name of Tester and Company:
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Fiacture Test: Pursuant to CFR 3280.612(c) Date: � ��'�_ �j
Print Name of Tester and Gompany: � /�t''�'�' ”
G8S TBSt: Pursuant to CFR 3280.705 and IFGC 406.4 Date: �� �,� , � l �s �
Print Name of Tester and Company: �j��/�y� �,1� �,� � }'�t�s,'��i t�� h� �� � ��
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EIeCtYiC11 Op@I"8ti0l1SI: Pursuant to CFR 3285.702 Date; ��Gl,�/
Print Name of Tester and Company: �j s��1 a��,'-(Z �r� ���
EI@Ct1'iCel POlarity: Pursuant to CFR 3285.702 Date: _ ��_ �.(
Print Name of Tester and Company: e�i �t
EleCtflCal COntittUity: Pursuantto CFR 3285.702 Date: Lj�y-��
Print Name of Tester and Company: ,� ,�,�
Smoke Aiarm Test: Pursuanc to CFR 3280.208 Date: ���2 )
Print Name of Tester and Company: ���
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I certify the above systems tesfing has been completed and was found to be in compliance witfi the provisions identified for each
systems test:
Si nature: ��� / ''�� '�
Date: