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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 32s0.612(b) Date:L� _� �-- � �
Print Name of Te r nd C � '"""`�.J ������
ste a ompany: e ,��. �p.S t e— �0.
Water Line: Pursuant to GFR 3280.612(a) Date: � � � 2 � �/���
Print Name of Tester and Company:
FiXtufe TeSt: Pursuant to CFR 3280.612(c) Date: f� —�� z' � /�7�
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Print Name of Tester and Company:
Gas TeSt: Pursuant to CFR 3280.705 and IFGC 406.4 Date: �'l�" � � �
Print Name of Tester and Company: r- "�—
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Electrical Operational: Pursuant to CFR 3285.702 Date: ` ��p--��
Print Name of Tester and Company: �--�,� l Q�,�,1��, �y�G i,,,. ���� �,���
Electrical Polarity: Pursuant to CFR 3285.702 Date: !`/—�j�- �—J/ �
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Print Name of Tester and Com pan y: �� �( � �I
EI@Ct1'ICaI COtttIllUliy: Pursuant to CFR 3285.702 Date: _3�-�2/ _
Print Name of Tester and Company: til `( �1j-
Srnoke Alarm Test: pursuant to cFR 3280.2os 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:
Si nature: pate: � ' J Q � �1