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Homeowner �/ '� <br />CITY OF EVERETT <br />GAS PIPING TEST AFFIDAVIT <br />i <br />1 �t�-I �l Il �( � i � <br />Address o��� C C L. Permit N�U`b � �6��7 <br />� � <br />The gas piping system was tested at__� i psi for a total of�� minutes. <br />WITNESSED BY /,�-. �� % �/�� <br />(si ature of occupant requesting yas aervice) —(date <br />INSTALLED BY <br />� <br />gas <br />�(date � <br />Please arrange for someone to be 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 />