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r <br /> ;iVOHt�MI�H ���.lEJY'�( CUNlMU��II"'. _ . . . . ..;���iT <br /> GAS PIPING TE�T AFFInAVl7 <br /> I AddresslJ ��„_�'� ��_Permit No�� <br /> Ths pa� pipfnp system wes tested at�psl for a total of sG� _mfnutes. <br /> �, WITNESSED BY N o o�nr hew� F�� <br /> (s gnature of occupant request ng ga— s servTc4) —Jdate <br /> INSTALLED BY <br /> gna ure of stali ng pas fitter) � ate <br /> When properly iflled out, both copies of this affidavit shall remain on site for fnspection. <br /> Please errange for someone to be present on tha date of requested fnspection to provide <br /> accessfortheinspector. <br />