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SNO_HOMISH COUNTY PLANNING & DEVELOPMENT SERVECES <br /> GAS PIPING TEST AFFIDAVIT <br /> • <br /> (Only for use in Occupied Buildings) <br /> Homeowner e40(1107 ACit6'irn <br /> OCT <br /> Address ,• ( $r t-vu-0144 Permit No. 21. <br /> The gas piping system was tested at /5 psi for a total /5 of minutes <br /> WITNESSED BY • v.. f \T-; <br /> 'signori)e or Omuparlt requesting gas ssrvice) (date) <br /> /1 <br /> INSTALLED BY %e9/1q /&;‘W67c-r:9641 <br /> signat_:re of instateng gas fitteri (9ate) <br /> Please arrange for someone to be present on the date of requested inspection to provide access for the <br /> inspector_ The white copy must be mailed to Snohomish County Planning & Development Services, <br /> MIS #604, 3,000 Rockefeller Avenue, Everett WA 98201-4046 upon completion <br /> White Copy-Mat Hard Copy- job Site <br /> 2,35. <br /> M3-177 <br /> - _ <br /> ccip <br />