HomeMy WebLinkAboutLA193296 - 825 MacBeth - Test Affidavit �����
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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.
SYSTEMS TEST VERIFICATION
Description Date Passed Signature of Tester
DPaltl L'It1@: Pursuant to CFR 3280.612(b) Date: �-a �� C
Print Name of Tester and Company: ^ � ���
e - Ge��. e e ��-S
Watet'Lttle: Pursuant to CFR 3280.B12(a) Date: ,r��� r
Print Name of Tester and Company: ��' _
FiXtu�e TeSt: Pursuant to CFR 3280.612(c) Date_,` �--� --Z
Print Name of Tester and Company: � �
Gas T�St: Pursuant to CFR 3280.705 and IFGC 406.4 Date: "]�?.,��a� -t-y
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Print Name of Tester and Company: ���y t v� - yyt�S*�fy yy�p b� (� �,y� s�e�U,,�-P
EI@Ct�ICBI Op@I'1t10118I: Pursuant to CFR 3285.702 Date: �Z�j''Z1
Print Name of Tester and Company: �,�r �,,�,,�s �rG�,� ��L'��"iC, ;-�`
Electrical Polarity: Pursuant to cFR s28s.�o2 oate: 7��Z f /���
Print Name of Tester and Company: ���� <�1,�� �����,.� ���r�G
✓
EI@CtrIC81 C011t111Ulty: Pursuant to CFR 3285.702 Date: 7•2(�- �
Print Name of Tester and Company: Z ar 5�����f jy'L✓�GG ��eGTr'i'
Smoke Alarm Test: Pursuant to cFR 3280.2os Date: �,� �
Print Name of Tester and Company: ,�-
1 certify the above systems testing has been completed and was found to be in compliance with the provisions identified for each
systems#est:
Si nature: Date: � � �� �
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