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�:,. <br /> CITY O� EVERETT <br /> GAS PIPING TEST AFFI9AVIT <br /> Homeowner j�✓���� � l��"�;A{/�l�/ _ <br /> Address_ _S�l - � �� ^i _ �1��'�.c;� Permit No. �Il'� � Z —��p� <br /> r <br /> Tlie gas pip'�g system was tested at � � psi for � total of�minutes. <br /> WITNESSED BY� � C'��� � � / <br /> (signature bf o cup�t reyuesting a service) ate � <br /> [..7Gi� f�r"tALl�itilc� <br /> INSTALLED BY � �� ��� � � � 1 I <br /> � ��� <br /> (signature of i talling gas fitter) (date <br /> Piease arrange for someone to be present on the date ot requested inspection co provide <br /> r,ccess for the inspector. <br /> ��'�ard Copy - Job Site Pink Copy - Contractor \Nhite Copy - Inspector <br />