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� <br />� <br />Homeowner <br />CITY OF EVERETT <br />GAS PIPING TEST AFFIDAVIT <br />Address aaz6 oici���ur,�.a✓ A��� - PermitNo. M/ /L7—O/g <br />The gas piping system was tested at / S psi for a total of_�_minutes. <br />WITNESSED BY <br />INSTALLED BY <br />r' <br />(signature of occupant requesnn�as service� <br />� date <br />!0 O$ � <br />(date <br />Please arrange (or someone to be present on the date of requested inspection to provide <br />access for the inspector. <br />� <br />Hard Copy - Job Site Pink Copy - Contractor White Copy - Inspectof ��r� <br />�_� <br />