HUD Inspection ReportInstants cion uenirrication UlTice o't ttllantat'acturecl Hoiii8ivact Progranis, Expires 04/3012018
And Verification Report
The Manufactured Housing installation Program Regulations 24 CFRChapter XX rar 286 Sections 11 and 411require the licensed installer certify that the
manufactured home has been installed and inspected in accordance with the regulatiorw. The Manufactured Housing Installation Program Regulations 24 CFR
ChapterXX Part 3286 Subpart F requires a qualified inspector verify that the rnanufachlred horne has been installed in accordance with the requirements of Part
3286 and Part 3286. The infomlation collected here vrill ensure that the licensed installers and rlualitied inspectars inspect the minimum elements for compliance.
The public record burden for the collection of information is estimated to average :3.5 hours per response including the time to review instructions, search existing
data sources, gather and maintain the data needed, and complete and review the collecrted information. Response to this information is mandatory. This agency
may not collect this information, andyou are not required to com)ale to this ion n unless the fom7 d hI S; ; a currency valid OMB control number,
i Certificntlon Label Numbcr(r,) Manufacturer's DAal Numbef(s) 1(tncludvGll•terosznUanancyprs3fiK) (lnctudoainener^anelnumUuro) John Podraza IL 20160066
!
►�ITA2020071/2020072 (fnsfallor Name) K1100174-IN A&B _ _.
, (MUD lgaonse No,)
Country Estates MHP _� _ Gilbert B Nebgen _ _ __.A _._.
I{Homeowner Name) (shte) I (InspectoriVame) (,,,late)
8520 Thompson Cyr Blair _ 68008 15750 Merlin Ln, Council Fluffs, 51501 402-917 6418
-_
1. Initial Inspection
inspection item �'
_
InD
ectorVerification
_»
-- Installer
Certification
_
r$ Pass
❑Fail
o N/A
i& s
�o Fall
n NIA
Site locator with respect to horns design and consWction
Consideration of site specific conditions
24 CFR 3285 Subpart C- Site preparation and grading for -
�I vl Pass
-�
o i ail
I I
❑ NIA
J! Pass
�—❑o Fail
❑ NIA
I drainage
I/Pass
ri Fail
o NiA
Pass
o Fail
NiA
24 CFR 3285 Subpart D - Foundation construction
V Pass
`V
n Fail
o N/A
I' t'ass
o Fail _
_ru NIA
_
24 CFR 3285 Subpart E -Anchorage
Pass_
o Faili�
o NIA
Pass
❑ Fail
ci NIA
�24 CFR 3285 Subpart F - Optional features (Skirling, etc.)
cr pass
Li Fall
❑ N/A�
Pass
o Fail
n NIA
24 CFR 3285 Subpart G - Completion of ductwork, plumbing,
wPass
n Fail
❑ N/A
I
I Pass
❑ Fail
n N/A E
I and fuel
I
�24 CFR 3285 Subpart H - Completion of electrical systems
i fir Pass
c, Fall
N/A
I APass
Fail
❑ N/A
24 CFR 3285 Subpart I -Exterior and interior dose up
Pass
o Fail
_o
o NlA
Pass�
Eci
Fail
�oNIA
r Completion of operational checks and adjustments
pt Pass
❑ Fall
o N/A
Pass
❑ FallI
2. Reinspection of Home (To be completed and initialed by the inspector)
If the inspector discovers that any item during the Initial inspection falls to comply with the manufacturer's installation instructions or with an installation
design and instructions that have been certified by a professional engineer or registered architect, the installation must be reinspected after the
lnstallatlon is corrected.
Describe the work performed following the initial inspection and if the reinspected items) are in compliance. Attach additional sheet(s) if necessary.
3. Inspector Verification
I hereby certify, in accordance with 24 CFR § 3286.507, that the manufactured home identified above has been installed in accordance with an
installation design and instructions that have been provided by the manufacturer and approved by the DAPIA or an installation design and instructions
that have been prepared and certified by a professional engineer or registered architect that have been approved by 1he manufacturer and the DAPIA as
providing a level of protection for residents of the home that equals or exceeds the protection provided by the federal installation standards in part 3285
of this chapter, it is a crime to knowingly make false statements and/or certifications in any matter within the jurisdiction of the United States such as the
certification on this or any similar form. Penalties upon conviction can include a fine and imprisonment. See 18 U.S. Code Section 1001,
am'-&g �� 07/2612021
I pector Signature - (Date)
4, Installer Certification
I hereby certify, in accordance with 24 CFR §§ 3286A 11 and 3286,411, that the manufactured home identified above has been installed In accordance
with an installation design and Instructions that have been provided by the manufacturer and approved by the DAPIA or an installation design and
instructions that have been prepared and certified by a professional engineer or registered architect that have been approved by the manufacturer and
the DAPIA as providing a level of protection for residents of the home that equals or exceeds the protection provided by the federal installation standards
in part 3286 of this chapter. it is a crime to knowingly make false statements and/or reriifications in any ruarter within the jurisdiction of the United States
such as the certification on �bis41, any similar fann. Penalties upon conviction can Include a fine and imprisonment. see `18 U.S. code Section 1001.
�= 07/06/2021
Installer naturer (Deli)
Form 11UU - 309
Disffibution:
Installer
Retailer
Purchaser