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CITY OF EVERETT <br /> GAS PIPING TEST AFFIDAVIT <br /> /� J <br /> Homeox•ner �, �. U� y�+�V�• _ <br /> Address�33.� K�ssc�Tr� A�� /l/- � Permit No. �4c —�'�' <br /> The gas piping system was tested at��psi for a total o��, 'r�minutes. <br /> WITNESSED BY � /��� <br /> (sign e of occupant requesting gas service) (date� <br /> INSTALLEO BY " � �y /�� <br /> (sig re of installing gas fitter) (date� <br /> Please arrange for someone to 6e present on the date of requested inspection to provide <br /> access for the inspector. <br /> Hard Copy - Job Site Pink Copy - Contractor White Copy - Inspector <br />