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��TY OF EVERETT <br /> GAS F�IPING TEST AFFIDAVIT <br /> Homeowner •� � ��u� -����' -;�;���.r—, <br /> Address 3 � l `� rti i- , • � F !��� Permit No. !`^ i � �-'6 - ��� L <br /> The gas piping system was tested at i � psi for a total of Lt �� minutes. <br /> � �_ <br /> � � - � �' <br /> WITNESS[D BY /� � � _, � � ✓��� �_/ r5� � r.) ; � <br /> (signature o1 occUpant.'requesting gas service) (date <br /> �- � - <br /> IfJSTALLED BY � �'��� ��' � <br /> � (signatC re of jnatal ing gas fitter) (date <br /> �'!case arrange,(�stimeone to be present on the date of requested inspection to provide <br /> .�ccess for the inspector. <br /> Har,i Copy - Job Site Pink Copy - Contractor White Copy - Inspector <br />