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SNO��f�ll��i ��OUNTY P�ANNING & DEVELOPMENT SERVICES <br />ONLY GAS PIPINC TEST AFFIDAVIT <br />OCCUPIED BUILDINGS <br />Homeowner <br />Address n <br />Gi <br />Permit <br />The gas piping system was tested at / 5 � h s. psi for a total of J:`�� _ minutes. <br />WITNESSED BY <br />INSTALLED BY <br />/>.� ��-��� <br />, <br />occupant requesting gas <br />(signaturo ot installinp gas fi.ter) <br />/G,;1y',:�20�� <br />(datc) <br />—/ /. <br />(tlate) <br />Please arrange for someone to be presant on the date of requested inspection to provide access <br />for the inspector. The white copy must be mailed to Snohomish County Planning & Development <br />Services, M/S � 604, 3000 Rockefeller Avenue, Everett WA 98201-4046 upon comr�letion. <br />Hard Copy - Job Site Pink Copy - Coniractor Whife Copy - Mail <br />I t; C} I I I 10.73� 10] <br />