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CITY O� EVERETT <br /> GAS PIPING TEST AFFIDAVIT <br /> Homeowner ' ' ' . � : t. . � " � ' " --- <br /> Address . :) [- ._-. Permit No. %] L '1� i � ' �/ <br /> lhe gas piping syster� was tested ai � �,_Pgi (or a total o( � `� minutes. <br /> 'wll NESSED BY J—� <br /> (signaWre ot occupant requ 1 ting g,as service) (date) <br /> INSTALLED BY ;, .� `, �' �� � `-� � --I� <br /> (sig�ature of irlstallmg gas titter) � (date <br /> F�icase arrange tor someone to be present on the dat! of requested inspection to provide <br /> ;�ccess for the inspector. <br /> Hard Copy - Job Site Pink Copy - Contractor White Copy - Inspector <br />