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Manufactured Home Svs�Eems Test Affidavrt
���w� MI
This form must be completed in its entirety and be submitted at'the Building Flnal inspection for the in$tallatlon af a
. manufactured home. Ap tests must be camp{eted and signed off on this form. A certificate of occupancy wiil not be
issued untfl this completed form is received.
SYSTEMS TEST VERtF[CATION
Descript�on Date Passed Signatura of Tester
Drain Line: Pursuant to CFR 3280.612(b) Date: ' �
Print Name ofTester and Company: �,�, � ` � �► ��� � -�— --., •�
Water Line: Pursuantto CFR 328Q.642(a) Date: C� .�-.�
RriM Name of Tester and Company� � � , /'"-�=' "��'�.
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FiKtUre TeSt: Pursuant fo CFR 3280.612(c) Date:
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Print Name ofTester and Cnmpany � r "�
Gas Test: Pursuant ta CFR 3280.705 an IFQC 408.4 Date;
Prtnt Name of Tester and Company:
Electrical Operational: Pursuant to CFR 3285.702 Date:
Print Name of Tester and Company:
Electrical Potarity: Pursuant to CFR 3285.702 t3ate:
Prirrt Name of Tester and Company:
Electrlcal Continuity; Pursuantto CFR 3288.702 Da#e:
Print Name of Tes#er and Company:
Smoke Alarm Tesfi: Pursuar�'t#o CFR 3280.2oe Date:
Print Name of Tesfer and Company:
I certify the above systems t_sting has been comple#ed and was found to be In comgttance wlth the provisians identlfied for each
sysfems test:
n u e: '�''".�,��.,-�'' ��V" �� Date: `'�����,,, �
Manufa�tured Home Svstems Test A�fidavit
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This fcrm must be com�leted in its er�tirety and be submitted at#he Bt�ilding Fina!inspectlan for the instai}ation of a
m�nufactur�d home. Aif tests must be�ompteted and s�gned off an th�s fiorm. A�er�I�tate of occ��ancy will not be
issued unti!�t�is com�leted#orm is received. �" I tyJ�O ����- �����- ' �
SYSTEMS TEST VERIFICATlQN
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Descripfion Date Passed Signature of Teste� ,
Drain Line: Pursua�to cFa 3280.s�z�j oate:
i
P�Name of Tester and Comp�ny: �
1NS�t8r LTIt@: Pt,�rse+ar�t ta GFR 3280.692{a) � �� � �
p�#Nar�e n#Tester and Cor�par�r: �
FiXtll�Tes#: Pursuant to CFR 3280.892(c) �e:
�rint Name of Tester and Campar�y: �
G2tS 1`@S$: Pursuar�t#o CFR 3280.705 and 1FGC 406.4 Date: ��j��..�d� � � . � ►
��r r���r�r�,a co�r�y:�jl�..i'1Ft� �GtS�C�", ��j 1����'�ti�,��.�i{�.. � � ���11 � r.�.. :
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Electrical Op�rr�#ional: Pursuar�c to c�t 28s.7oz oa�e: I
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Print tJame of Tester and Company: �
Elec�rlcal Polariiy: Pursuant#o C�'R 3285.702 Date: �
pr�nt f�iame af Tester and Comparry: i
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EIQ�tt'iC�l COlitItlU�$y: �ursuant io CFR�285.702 Date: ,
P�nt Name of Tester and Campany:
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5mo�Aiar�»i'e5t: nursuar�to c�a sz$o.2os �� �
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Pricrt,Name o#Tester and Company.
I cettify the above systerri�testing has been campte#ed and wa�found#a be in corrspliance with th�provistons ider�ti�ed for each
systems tsst:
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Manufactured Hor�e S�stema Test Affidav�t
Th1s form must be cor�,pleted in its entirety and be submitted at#he Bt�ilding Finaf inspectlan for the installa#ion of a
manufactured hflme. Ali tests must be compfeted and signed off fln th�s form. A terti�cate of accupancy wi!!not b�
tssued until t�9s cflmpleted#orm 9s received. �� ��� ���� f� ' �
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SYSTEMS TEST VEREF1CATt�N
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Description Date Passed Signatur�of 7ester .
Draln Line: Pursuar�t to CFR 328as�z@) oate:
_ i
Print Name of Tester and Company: - i
W�ter Lir�e: Purse�ant to c�ra szso.692{a) � n�s�e: ;
Print I�ame crf i'ester srad Corrtpa�y: �
1Fixtur�Tes� Pursua�t to CFR S?..�o.s1z(c) Date:
Pr3at Name of Tester and Company:
GaS Y@S$: Pu�uaT�t to CFR 3280.705 a17d lFGC 406.4 Date: �-'���,�}� �.. -�"" i
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Ptint Name o€Testerand Company:�j��, GtS��,{k � �S���i,�,p(.�i(�. � ��t c�C... �
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Electricat Operational: Pursuant to CFR .7a,2 ��� �
Prirrt tJsme of Tester and ComPa�y.
Etecf�icai Polartty: Pursuant fo CFR 3Z85.702 Date: �
Pr3nf ldame of Tester and Camparry: ;
Eiectric�i Cor�tit�uit�: Pursuant to CFR 328�.702 fl��� ,
Print Name of Tester and Campaay:
Sf�10k@ AWI?Y!TESf: Pursuentta C�R 3280.208 Date: :
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Pdcrt Name o#Testsr and Company:
I Cettlfy#te abc3ve systerrts testing has been comp��fed and was found fo be in corttpiianc�wtth the provislons ideMiTied far each
systems tes#:
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