HomeMy WebLinkAboutLA192595 . �
�� 1� Z5 _t�
Manu#actured Home Svstems Test�davit
(his form must be completed in its entirety and be submitted at the Building Final ins�ction for the ins�ailation of a
nanufadured home. Ail tests must be completed and signed off on this form. A ce�ificate of occupancy wiil not be
ssued until this completed form is received. / y]� � u��L_L'�: �V�C�
� � �-- !� ---�—�
SYSTEIAS TEST VER1FlCATI4N �
Description � Date Passed � Signature of Tester
��
Dr"dltt Litt@: Pursuarrt to CFR 3280.6i2(bj Date: �
;
�nrrt Name of Tester and Company: {
Water Llne: oursuantta CfR 3,28fl.s�2(a) Date: '
Prirrt Name of Tester anci Comparry: �
Fixture Te�� Pursuarrt to CFR 3280.6t 2(c) Date_ � i
. 1
Print IVame of Tester anci Company: f
CsaB TsSt: Pursuant to GFR 3280.705 and IFGC 406.4 Date, .-� - ~-"" """'"1
�: _�._.'�'� ;
Print Name of Tester and Campany: CJ� ���'i�-+ ���j� � �,k V 1�t.." �
Electriical Operational: �ursuanc to c� 2ss.7oz Date_
�riM Name of Tester and Campany:
E1ec�r�cal Palarity: PursLaU►t m c��t�.�02 �: '
(
�rirtt Name of Tester and Company: �
�----i
�
=f�G!'17G31 CORtu11ilty: Pursuar�l to CFR 3285_7Q2 �: �
� i
�rint Name of Tester and Ccxnpany: r
3ntOke Alarm Test Pursuant to CFR 3280208 d�: ;
i
'rirrt Name af Tesie�and ComP�Y
cerMyr the aba�syaterr�s t�has b�en compf�d arui was faund to be in cornpiiance v�a�tfie provisians identified for each �
��
1
-� � '�c�'� '
..�--� ('} ,
>i nabure: �.� �' ��
� � �. � 1g 2�� 5 :
.�
,�:a ��w��
, .; .
Manufactured Home Svstems Test Affidavit
This form must be complete�l in its entirety and be submitted at the Building final inspection for the installation nf a
manufactured home. All tests must be completed and signed off on this form. A certificate of occupancy will not be
issued untii this completed form is received. � � 5 �a Eu fe�,c� AVC.
SYSTEMS TEST VERIFICATION
Description Date Passed Signature of Tester
DI'litt LI11@: Pursuant to CFR 3280.612(b) Date: � �
Print Name of Tester and Gompany: (,���Y ������: , ,,� , ` ---�._.,,,...,-�'"
WBteP Litte: Pursuant to CFR 3280.612(a) Date: � ��
Print Name ofiTester and Company: � ����.� i ' .� �d-u---.._.----��''
Fixture Test: Pursuant to CFR 3280.612_(c) Date: � �Z Z�
Print Name of Tester and Company: � � z s�'"� �
�_ :.
GaS T@St: Pursuant to CFR 32$OJ05 and IF�C 406,4 Date:
Print Name of Tester and Company:
Electrical Operational: Pursuant to cFR 32ss.7o2 Date:
Print Name of Tester and Company:
E12C'CCIC81 PQ11PIty: Pursuant to CFR 3285,7Q2 Date:
Prrnt lVame of Tester and Company:
EleCtt'iCal COrltittuity: Pursuant to CFR 3285.702 Date:
Print Name ofTester and Gompany:
Smoke Alarm Test: Pursuant to cFR 3280.2os Date:
Print Name ofTester and Company: �� �'�,"�..�,���1� ����*�.���
I certify the above system testing has been completed and was found to be in compliance with the provisians identified for each
systems test:
�,�_,..,, .o� � /��
Si n t re: '� Lv+^t7 i�° k/"j�:,+� Date: � ' 1