HomeMy WebLinkAboutLA193936 - Affidavit t �
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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
DP81t1 L'111@: Pursuant to CFR 3280.6Y2(b) Date: �.�, � � /����—^1
Pri�t Name of Tester and Company: �, G� �� Q'f Y _
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W8t@f Ll lle: Pursuant to CFR 3280.612(a) Date: J, � �'.- ��
Print Name of Tester and Company: .-riL_.�
FIXtUI'e TeSt: Pursuant to CFR 3280.612(c) Date: j� _ �� � a� �
Print Name of Tester and Company: !��-��
G1S TeSt: Pursuant to CFR 3280.705 and IFGC 406.4 Date: ��-�, �,,,. �., �
Print Name of Tester and Company: - � r�ts��
�'�`�'`y� "�lis� �()��l� �i'►� �Cai�Ur L,p
Electrical Operational: Pursuant to CFR 3285.702 Date:��—��—�-�
Print Name of Tester and Company: �.-�-��—r��������� 1.-7 _ _
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EI@Ctt'ICBI P0111'It�/: Pursuant to CFR 3285.702 Date: j�j—�� _ �
Print Name of Tester and Company: L t Z( �(
EIeCtPIC81 ColltittUity: Pursuant to CFR 3285.702 Date: `v _� � ���
Print Name of Tester and Company: L� C ��
Smoke Alarm Test: Pursuant to CFR 3280.208 Date: �1� �� a� �
P n n t N a m e o f T e s t e r a n d C o m p a n y: /��,}��
1 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: ���' ���`