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� CITY OF EVERETT <br /> _�'' PIPING TEST AFFIDAVIT' <br /> o�vner / i<<=1� � `,��n'�=. - <br /> Job Address 1.s D� /�rs���s- ��/ � isi.=c:: : Permit No. �� n `���� ���Cl <br /> The reirigerant line / natural / LP / medical gas system (circle one) was tested at psi for a <br /> iotai of l -' minuies. <br /> ! 'VITNESSED BY � ,�, �� l�rt� Date ,��f���� <br /> ign ture o�ggeflpa�Tr t re uesting gas serv�cc� <br /> � i�1STALLED BYft I)�'.:;�t' %c•I 1.�°>/��/� /:" — Date _ -� � _ <br /> �I nawre ui maiduuiy ya�S7TfT�-----� — <br /> I <br /> I'lease arran���� fo� somcoru� (o bc �irescri on the c'.ate o� requested inspection to provide access for <br /> �I�ie inspecti�,n. <br /> ��LPRIGC-RANiC.�_:�.� � i����- ''�'�I`, i'lii_ ' . .��il'.I SGIf_Li� !IiCG1t-D3Hql.tf3ETE5TEDFORL[.1KATTESTPRESSURESNO'. <br /> , ���SS THAN 7HF L'UIY�H Uf= I ilG U�SIG?; Ri�'tSSURCS OR 1NE SL I�i It{G OP 1HE PP.LSSURE RELIEF UEVICES. THE DESIGN PRESSUFE <br /> ! .�?-�-f'.;71'iG SHALL 6E THOS[LIST[U ON THE CONUENSING UNII�OH COIdPRESSOR UNR NAMEPLATE.('vVAC 51�42�1108! <br /> I Ic�r�.1 Cepy - Job Sit� Pink Copy- Contracior White Copy- Inspector <br />