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CITY OF EVERETT <br />GAS PIPING TEST AFFIDAVIT <br />Homeowner S' r.�, -/-7- <br />Address C / 'c A Permit No. MG 15 7%3 <br />The gas piping system was tested at Lam, 5_psi for a total of l C-� minutes. <br />WITNESSED BY <br />(signature of occupant requesting gas service) <br />INSTALLED BY <br />Z <br />date <br />date <br />Please arrange for someone to be present on the dale of requested inspection to provide <br />access for the inspector. <br />Hard Copy -Job Site Pink Copy - Contractor White Copy - Inspector <br />