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% <br /> C;ITY OF �0/ERETT <br /> _ GAS PIPING 1 E�T AFFIDAVIT <br /> �' � -- <br /> Homeowner -N c, � /-. <br /> '—`�' <br /> Address_ n���� ��? h'l � �-'- Permit No1�1 0� � I � C���-`� <br /> �— — <br /> il���� r�as piping syster.i was tested at ,_��__._ —Psi for a total of_._���_minutes. <br /> � <br /> WITNESSED BY '�� �-`-� ,� c� �� `-'' � � � �"� � � � <br /> (signature of oc pa� ,requesting gas service) (date) <br /> . � , <br /> �I It1STALLED BY �;• �i:�'��—� ,ll_1-r -� — � �� ��� <br /> (signature f nstalling gas fitter) (date) <br /> I <br /> �'i��ase arrange (or someone to be present on lhe date of requested inspection to provide <br /> ::�:cess for ihe inspector. <br /> !ir��d Copy - Joh Si1c Pink �r,py - Contractor White Copy - Inspector <br />