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Manufactured Home Svstems Test Affictavit
This form must be completed in its entirety and be subrnitted at the Building Fina!inspection far the instaliation of a
manufactured home. All tests must be compieted and signed off on this form. A certificate of accupancy wiN not be
issued untii this campieted form is received.
SYSTEMS TEST VE�tIFICATION
Description Date Passed Signature of Tester
Drain Line: Pursuarrt to CFR 328Q.612(b) Date: �._ � � j �� ��
Print Name of Tester and Company. �� f+ � _ ��
Water Ltne; Pursuant to CFR 3280.612(a) pate: _ _�1
� �Print Name of Tester and Gompany: .�
Fi�cture Test: Pursuant to CFR 3280.612(c) Date: _I _�
Print Name of Tester and Company: �� �k��
GaS TeSt: Pursuant to CFR 3280.705 and IFGC 406.4 Date: �� �.,� , � � `#-�,-�, �
f.�,.._ �,�-
Print Name of Tester and Company: ���/��, �( � �� � ��5,��i �� h}'�� � v��
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Electrical Operational: Pursuant to CFR 3285.7U2 Date: ��-��,a�,�.-�
Print Name of Tester and Company: ��.P�.� j��� ���
6 ��
EI�CtriC81 P018Pity: Pursuant to CFR 3285.702 Date: !��- 3����
Print Name of Tester and Company: �� r f
Eleetrica{Continuity: Pursuant to CFR 3285.702 Date: �—'����2 �
Print Name of Tester and Company_ Ut � (
Smoke Alarm Test: Pursuant to CFR 3280.208 Date: ...3� ._� ,
Print Name of Tester and Company: � � ,
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1 certify the above systems tesfing has been completed and was found to be in compliance with the provisions identified far each
systems test:
Si nature: "
��✓r�t,��e' Date: � � �