HomeMy WebLinkAboutLA193298 - 851 MacBeth - Affidavit � �-( ,M�� b.�.� �
�
� �� � '
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'1111 Li11@: Pursuant to CFR 3280.612(b) Date:
Print Name of Tester and Company: �� �r �� :� _.�� � `
Wate1'Line: Pursuant to CFR 3280.612(a) Date: g l ,_
Print Name of Tester and Company: � ,<�
Fi�cture Test: Pursuant to CFR 3280.612(c) Date: �l „_
Pnnt Name of Tester and Company: �
/
GaS Test: Pursuant to CFR 3280.705 and IFGC 406.4 Date: ��'3� �- �. '� �
Print Name of Tester and Com an : � ��
p y I�v`�r �— Yt�c.S�fi"Q� Y�►-o 1��; �� I�p�Q �iJ�
Electrical Operational: Pursuant to cFR s2ss.�o2 �ate: �9 Z/ �
P r i�t N a m e o f T e s t e r a n d C o m p a n y: ��/�/�i; ��i�G ���/^N G
EI@Ctt'iC81 P0181'Ity: Pursuant to CFR 3285J02 Date: �q�Z� �
Print Name of Tester and Company: �� �f-�p�Jr. �Cy�u /��G�r,�
Electrical Continuity: Pursuant to CFR 3285.702 Date: g 9-Z� �
Print Name of Tester and Company: �i� �/�j� i�C!''G�iIY ��G7�"l'G
Stl10k@ AI81'117 TeSt: Pursuant to CFR 3280.2U8 Date:�� ,...� 1
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:
Si nature: Date: ���� � `