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CITY O� EVERETT <br /> GAS PIPING TEST AFFIDAVIT <br /> Homeowner_ �nl'2l-��t�l <br /> Address i Lp �2Tianl A�IF E� k►'1 �t°�ZD I Permit No. <br /> The gas piping system was tested at ZU psi for a total o} 3v minutes. <br /> , / <br /> WITNESSEO BY � � 3Js—� <br /> (signature o occupant requestiny gas service) (date <br /> INSTALLED BY 3 �SJ� <br /> ' natur o insta gas fitter) (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 />