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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. Ail tests must be completed and signed off on this form. A certificate of occupancy wili not be
issued until this completed form is received. �,,;�%�i� �
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SYSTEMS TEST VERIFICATION
Description Date Passed Signature of Tester
Drain Line: Pursuant to CFR 3280.612(b) Datert�, '%c�-Z'i /� ��-�
Print Name of Tester and Company: �,C,� ������ �'�l ������ ., f .. %7
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Water Line: Pursuant to CFR 3280.612(a) Date:� ,.��, _�, � � �- j
Print Name of Tester and Com an : � " / /'' _- �. �
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FIXtUt'@ T@St: Pursuant to CFR 3280.612(c) Date:�;� i(� -�i � � ---�
Print Name of Tester and Company: ' � -f' /�^� � `
� ,�c�:�\�.�.�-�� �\�::.cl� ��;����.'�,�
GaS TeSt: Pursuant to CFR 3280.705 and IFGC 406.4 i Date:
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Print Name of Tester and Company:
Electrical Operational: Pursuant to CFR 3285.702 �ate:
Print Name of Tester and Company:
Electrical Polarity: Pursuant to CFR 3285.702 Date:
Print Name of Tester and Company:
Electrical Continuity: Pursuant to CFR 3285.702 Date:
Print Name of Tester and Company:
Smoke Alarm Test: Pursuanc to CFR 32aozos �ate: I
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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i nature: -� �- '`-� �J✓' �j�-(0� Date`" ..rC> �i
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Manufactured Home Svstems Test Affidavit
fhis form must be completed in its entirety and be submitted at the Building Final inspection for the install�tion cf a
nanufactured home. All tests must be completed and signed off on this form. A certificate of occupancy will not be
ssued until this completed form is received. �J/,,, � ���j ��� ��/�, ��
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^ SYSTEMS TEST VERIFICATtON ' j
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� Descripfion � Date Passed � Signatw e of Tester �
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Drain Line: Pursua�to cFR s2so.s�2�b) �ate: '
�rint Name of Tester and Company: � �
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W2t�LIf1e: Pursuant to CFR 3280.612(a) � Date: I '
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�rirrt Name of Tester a�d Company: I
FIXttJf@ TeSt� Pursuant to CFR 3280.612(c) Date: �
I
Print Name of Tester and Company: �
G2S T@S� Pursuartt to CFR 3280.705 and lFGC 406.4 Date:� - �� - �.� �- -.� -=� ,
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Print Name of 7ester and Company:��� �u�C C�.� ���)� � �.-�1�ny� �(,�,,
EI@CtrIG3) OpG�lO�tal: Pursuant to CFR 3285.702 ( Date: �
�rint Name of l"ester and Company:
EleCtriC11 P013fity: Pursuant to CFR 3285.702 Date: �
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�rint Name of Tester and Company:
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=1�Cd'IG31 COtttlituity: Pursuant to CFR 3285_702 �ate: 1
i
'rirrt Name of Tester a�d Company:
3t770ke Alat'm Test Pursuant ba CFR 328Q208 Date: �
- - ;
'rirrt Name of Tester ar►d Cornpany �
certify the above syster»s testing h�been compl�ted and was found to be in c�rnPliance with the provisions identified for each �
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