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�anu�c#ur+ed Hc�me Svstem� Te�t Affid�vit
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►is form �ust be cc�mpl�ted in its entirety�nci be submitted at the 8uildin��inal inspectic�n far the instalfati�n�f a
anu#�ctured h�m�. Af)tests must be cc�mpleted artd si�neci off an this form. A cer-�ificate af occupan�y will nr�t be
aued until this completed t�vrrn is receiv�d.
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SYSTE3VIS TF�T VERlFICAT�QN '
Descrip�ic�n C►ate �'�ssed j �ignature af T�ste� �
i`�ilt �itte: Pu�suarrt#o CFR 3280.612(b} C}ate. '
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int Name o#Test�r anci Gompany: '
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datE�r Litie: ?�ursuant to C�(�3�8�.s12(a} � t?ate: ;
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�irrt Name of Tester ancf Cam�ny:
IXtuc'e TE3St: Pur�uant to GFFt 328Q.692(c� [7ate:
-int Na�te of Tester and Company: (
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��T�«3�. Pursuanf to GFR 328{}.7Ct5 and IfiGC�4Q6.4 i3ate: ���_�� ' '---'"--�� "'
rint Alame af T�ster an�i Gornpany_ � ?
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lec�icat C}p�r�ttionaE: Rursu�rrt tcr c� s2s�.�o2 oate: �
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�nt�Iame�f Tsster and Company. �
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IeCtt'li�2tt Poi�#'�ty: Purtsuuant to CFR 328�.7t32 Ct�te: ;
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int Nam�of 7ester and Company: E
Ic�Gtt7Ca1 CaPttintli'f�#: Pursuant to CFFt 328�.7Q� Gate: ;
�nt Name o€Tester and Gamp�ny: �
moke Alarm Test: �u,�s�,ant t���€��2sa.2�s t�ate. �
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int#�ame of Tesier arrd Campar�y_ '
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�ettify 1�e above systems�estir�g h�s k�esa carnpl�#ed at�d�as founti to be in cump�iar�ce�h the�rcrvisi4r�s ici�ntifi�d for each ;
st�ms test: �
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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.
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SYSTEMS TEST VERIFICATION
Description Date Passed ' ature of Tester
Drain Line: Pursuant to CFR 3280.612 (b) Date:
Print Name of Tester and Company:
Wat@P LI11e: Pursuant to CFR 3280.612 (a) � Date:
Print Name of Tester and Company:
FIXtUre TeSt: Pursuant to CFR 3280.612 (c) ` ' Uate:
Print Name of Tester and Company:
GaS TeSt: Pursuant to CFR 3280.705 and IFGC 4Q6.4 Date:
Print Name of Tester and Company:
Electrical Operational: Pursuant to CFR 3285.702 Date:
Print Name of Tester and Company:
EI@CtCIC81 P0181'It�/: Pursuant to CFR 3285.702 Date:
Print Name of Tester and Company:
EI@CtPIC81 COI1t111Ulty: Pursuant to CFR 3285.702 Date:
Print Name of Tester and Company:
Smoke Alarm Test: Pursuant to CFR 3280.208 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:
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Si nature: Date: ..-� �`� � �-
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ELECTRICAL AFFIDAVIT
THIS CERTIFICATE MUST BE FILLED OUT COMPLETELY BY THE ELECTRICAL
CONTRACTOR AND FILED WITH THE ELECTRICAL UTILITY BEFORE ELECTRICAL SERVICE
CAN BE CONNECTED
Permit#: LA 190644
Job Site Address: ��701 Kenyon Ave Lot 53, Lakeville MN 55044
owner:Riverside Communities
Electrical Contractor/Company Name:Live Wire Electrical Services
Contractor License# CA Master Electrician License#:EA006172
Mailing Address (Contractor, Company or Owner Performing Installation):
Street Address PO Box 446
Cit �santi State Mn Zip Code 55040
Office Phone#651-688-2400 Contact Phone#:612-363-1470
Printed Name ofiAuthorized Individual:Tammy Herman
Authorized Signature: �
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AMPERAGE SIZE 200 AMP
SERVICE ENTRANCE CONDUCTOR SIZE N/A
THREE PHASE SINGLE PHASE X
DATE UTILITY CONNECTION IS REQUESTED 05/202021
Lakeville Utility Providers:
Dakota Electric
Xcel Energy
2/28/2006