HomeMy WebLinkAboutLA193297 - 845 MacBeth - Affidavit � � � 1�� c �� �"�
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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
DI'a111 L111@: Pursuartt to CFR 3280.612(b) Date: -. � —� �
Print Name of Tester artd Company: � .,v� .�
Y G�O � e — C�'�
Water Line: Pursuant to CFR 3280.612(a) Date: ���.
Print Name of Tester and Company: �����
FiXture Test: Pursuant to CFR 3280.612(c) Date: �����Zl
Pnnt Name of Tester and Company: � �
GaS TeSt: Pursuant to CFR 3280.705 and IFGC 406.4 Date: 7.�p,'�. / � oi�1�-c
Print Name of Tester and Company: ��V�N _ ��S�e✓ h'ta�%l'� Y'�e►^^�Q �N fu�4
EIeCt1'iC81 Op�P1t101181: Pursuant to CFR 3285.702 Date: _�;y � �
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Print Name of T e s ter an d Company: �-��
5�v� �,M .��f� ir�t-r�G�-. �71z L '�
Electrical Polarity: Pursuant to cFR 3as5.�o2 �ate: S_�(
Print Name of Tester and Company:
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ElectricalContinuity: PursuanttoCFR3285.702 Date: ���.s�/
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Print Name of Tester and Company:
Smoke Alarm Test: Pursuant to CFR 3280.208 Date: g.�,�Z ' r
Print Name of Tester and Gompany: ����z�
I certify the above s stems testing has been completed and was found to be in compliance witti the provisions identified for each
systems test:
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Si nature: ��� '� �
Date: