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CITY OF EVERETT <br /> GAS PIPING TEST AFFIDAVIT <br /> z ,/ <br /> Homeowner �6 Q ��� <br /> • �4"�j' /� 1 �RPn2� Permit No.�� (/ <br /> Address � � n�� <br /> The gas pipin9 system was tested at �S si for a total of d Q minutes. <br /> WITNESSED B �" "'v —1 date <br /> iy ure of o pant requestiny �as serv�ce) ( <br /> ' �u�.� <br /> INSTALLED BY date <br /> ature of installiny pas fitter) ( <br /> Piease arrange for someone to be present on the date of roquested inspection to provide <br /> access for the inspector. <br /> Hard Copy - Job Site Pink Copy - Contractor White Copy - Inspector <br />