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\ <br /> CITY OF EVERETT <br /> Homeowner GAS PIPING TEST AFFIDAVIT <br /> .�i�,•-, l��vD�JI�-� <br /> Addross �. � � �� i�, �1 ll, Il iU,� �1` Permit No. 19� `� 7 5 �3 <br /> The p�s pipinp syst�m w�� tested �t � � osi for � total of�_minutea. <br /> � I( / � / 7 <br /> WITNESSEDBY � �ilAl � �,l � � -- I _ <br /> (s�pna�ure o occupant nqu st ep pas s�rv c� � �te � <br /> INSTALLED BY � l^ � ^l1'1fi/1---- . � /E,'� <br /> (s pn�tur� o nstal np ��s tter �te} <br /> Please arnnps for someone to be present on lhe d�b of nqu��ted inapection to provide <br /> accesafortheinapsctor. <br /> , Hard Copy - Job Site Pink Copy - Contrtctor Whit� Copy - Inspector <br />� <br />