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CITY OF EVERETT <br /> GAS PIPING TEST AFFIDAVIT <br /> Homeowner���_ lJ.)C,�j-'�C�,P` _ <br /> Address_�`�� �,Z'�__�2 Permit No. /=/0�015 _�,� <br /> The was tested at /� OC� psi for a �;otal of�_minutes. <br /> �-p�T/ � �i-fz 1 !in Q� <br /> , <br /> WITNESSED BY � '�{� � �� = r ��� � 7I � ,'C-' C% � C <br /> /� Il r _ �� �1 � <br /> (sif�nature ot occupant requesting gas service) (date <br /> �,'`� ,�� �" �� .. � <br /> INSTALLED BY `i�i_��( �-� .�.. ' ` ,: � . .%n;�� _• C c , �� � � `' <br /> (signature of installing gas fitter) �v �(date � <br /> Please arrange for someone to be present on ihe date of requested inspection to provide <br /> access for the inspector. <br /> ti <br /> Hard Copy - Job Site Pink Copy - Contractor White Copy - Inspector <br />