Loading...
HomeMy WebLinkAboutLA175832 - Affidavits . .� , . � �� i� ���rL t!�lanu�EL�a,.,d�1o,�.`�v�t�„�,"�'�s���flc�„it Tttis f�rrrn must be corrtp�eted tn its ent3r�ty ar�d b�s�brnitied at tt�e 8uilding Fina!�nspection ftsr the lnstai�tlan of a rnenuf�rtured t�rne, All t�s#s must lx c�mp�etad a�nd s�ned off an th�sform. A teRtflc�te af occupar�.y witt r�t be �su�d unti!this�r�p�;ted it»rr,�rcceivett. � �"7 � l..' � ��.., ���y �� . � � y � { � � SYS"�"�M8 T'EST V'ERIFi�I�tTI C�seriptic�n L3�te Pes�ed ��na1�t'e o1 Test�r Ctraln Line:Pur�u�to cFR 3�80.8�2(t�� t�ate: prhM Name of?es#er and Compat�y: W��tt'I.i�: M to CFR;i2�}.8�2(e) C�: Print N�cne afi 7 end Gt�n�any: Fb�t�PB TB�#: Puseuent�CFR 32�(1.612(c� t}e�: '^� P+tnt Name c�Te�ste�snd Gompany: C3�s T+�t:�+mruern to c��z�.T�,ancr iF�c ao�.a [�te: j�,- 9- �� � P�int Name+�7e�ter end�r�y: �,�;�,, r+���"�t Yh.�;�,�� �4,�.c S�a r;c.� E�trical flper�atic�r�1: �arn�c��3ze�_�o2 c�s: Priert Na�rse c�f T�'�xi Ca�y: E1i�cti"�Cait Pt}liat`tty: Purat,+�'�t to C�R 3z85,702 Dste: Rr1nt Na�me ttiT�rs�e�ettd Gort�reny: E��it'���tMtt1l�ttit�t�1': Ptxit,�'ri to CFi2 32�5.Tt12 D�: Print Name a�Teater snd Csutlp�ny: $i1't01C41�8t'qi TYS#: Purt�erd!v CFR 328t3.� DBte: P�tl�t Na�r�e oi"Testeq'�Id GcsmperrY• I�tlC�+tli�ahov�r aystem� hsa be�n ao�ttqleterf 8�d�tound to be�cartp�wE�t tha provlQkx�e idsr�Hl4d far each � , ��: � � ��� t� r ��7a� 1�.�,-,y,,�, f}-�� =����` ?��} i���� ����Z ��c������r��c� ��rr�� �S �t�r�n� '�e�� �#�ic�avi� This f�arm must E�e ccamplet�d in iCs �r�Cirety�nd be s€�brr7i�ted at 2h��uilt�irg�inal insp�ctit�n f�ar�he ins�al€aticsr� r��nufactured htame. Rll tests rrtust b�ccrrnpl�tet� and si�ned c�f�c�n thi�ft�rm. A c�rtificate c�F occupancy wilP r�o�be #ss���d unti�this c�r�°�pleted�orm is recerv�d. �� �--�----_____�. _____ __��_._.________.._�. �.�. i_. s`�'�T'��� �'��T��������T���! --._..__... ; -- ----------�-� _�__._ _.__ , ` [�esct-�ptit�n ----'-- _ r �'°,, ���� ��ss�d �igr��ture c�f T�st�r � � L�����a LiC1£: Purst�anf te��F�328C�,612{b} [ --- .� � C�at� � � l�rarf I�am�flf?'�st�r��d��r;�p��y ..._____— ""� 1 i � i ����i"l.€t��; Pursu�r��Et�GFR 328C�.�1�(�� -�,` �--- i�ate: - ---------------__ � a Print��rne crf Tester�nd Cc��pany: � �:� � � �E����� T���: F'ursU�nt tc�CFR 328Q.612{cj L�ate �_�__�...�.�_... _____.__ __.�_�_ � �._�_--� _�____... � �Pr,'r���arr�e c�f�°esfer�nd Ctasr�pany_ � 1 � � ��� �`���: �'urs�t�nt t�CF�328f�.�(7�and IF�G�E76.�t �ate. ;---_ .__" ._.__ .. ,_� ; x P�����m��f�`��t�r�r�d Cc�m ae� � ( �a,���� P 5�; � , °�' ! i �����1l��� ��E.'t"����961t'��' €'U,"�ta�rlt ft7�FR 3��5.7t�2 , --_ � ' ..�.- ' � C7ate� ���� � -. �...�-y�" --,.�..--�~"�.�.�I _ �----- _.._ _�____� `'�,��� 1 -�.�______ .....�.__.�___ __�..�_._ ___ . ---,�--_ ____..____,.__..._. ' �rint t�an��r���t'e�ter ar�d �c�rr����y: ; � 1 �����C��:c�l �ttl�t��y: F��rsuant tr�C�R 32�5.702 p�t� ___�._ € .� _�_ �x�- ��-�_. �_.��.��______-. � . �.,��--�.. _�_.________. .�.. � � �'rrr��#��m��f"�est�r��nd Gc�rni��rry= � ���r���3 ��r�t�n��� �u { ( �'. f�'(1,r�i'f��CJ������5'�.?'�� � �}���: �'�� j ( - - rsaw v'3 ( --- __._.._. a._. � j�`�g'��;�� � � � �rin�P��r��,�f Teste;anc�C�r�sp�ny_ � I i �� t ; ; � ���� ���rt�M 7`���: Purs�ant fo GFR 328�.�{}� D�t� r �-.w__�___._.___.__ __ , _------____......�_ � � Pri�r€ri�a��o€T�st�r�nd Cc�r�p�ny: __ _ ._...� � l ` � I � I c�r��sfy 4he���,v�sy�f�ens te�tinc�r�as b��n ct�mp���c�1 ar�d w��c��r�d tr�b�ir corr��Cian€:�vrith t€�Q�rovisicrns id�r7tified fc3r����, i � sy�t�rr-�s#���: ��r �,�-�� �„,. ,. ��..�-� � ���` �.,�,..„..� ��.�_ � s�. � r' � fF";� � �� ; . � �.� �� _ D�te � ,< w. � .__._ _,____ ---��____ ; .__�____.__�,. ___....