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� , <br /> CITIi( OF EVERETT <br /> GAS PIPING TE5T AFFIDAVIT <br /> Homeowner � • T �e.0. C�pLk,, <br /> Address \�0 2 S �c� 2�v�n �:� r' L0.n�- . Permit NoM9Q�4- a!J? <br /> T <br /> The gas piping system was tested at_�__psi for a total of�minutes. <br /> o cr9 � <br /> WITNESSED BY_ � ��,G��-az>c� f ZJG� <br /> (sipnature of occupant requestinp yas service) (date <br /> � <br /> INSTALLED BY �� `� q <br /> (signature of instal ' g gas fltter) �date � <br /> Please arrange tor someone to be present on the date ot requeated inapectfon to provide <br /> access for the inspector. <br /> Hard Copy - Job Site Pink Copy - Contractor Whfte Copy - Inspector <br />