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CITY OF LVERETT <br /> GAS PIPING TEST AFFIDAVIT <br /> Homeowner `�31 � _ ��� f V L-@ �'�-�'� �A �� <br /> Address �� �l� � � `-� �� '��� Permit No.���'�.��j <br /> l he gas piping syslem was tested at �l � psi (or a total o( � -� minutes. <br /> WITNESSED BY � �.l�i�— <br /> (s' a ure ccupant requestinp qas service) (date <br /> INSTALLED BY / 4s+ V�'/ ' `'��''�� ��� <br /> (signature of in alling gas fitter) (date <br /> Please arrange for aomeone to be prcsent on the date of requeated fnspectfon to provide <br /> access for the inspector. <br /> Hard Copy - Job Site Pink Copy - Contrector White Copy - Inspector <br />