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�� <br />� <br />CiYY OF EVERETT <br />PIPING TEST AFFIDAVIT <br />Owner � ��-%�C../�- -/-� �J ^- - - <br />Job Address _ �� �� %�� �%C%�.C`:� ---- - -- Permit No. �o�C./ !_ - �-'�`c�- <br />� -- ����- ' <br />The reirigerant line / natural / LP ! medical gas system (circle one) was tested al �� _ psi fur a <br />total of __J� minutes. <br />WITNESSED (3Y C1lt2�tti- ���'G�`=''-"- ----- ---- Date _lz--�=/Z,— ----- <br />(Si9naiwe al occupanl reqUesiing gas service) <br />{-� <br />INSTALLED BY � W� �'''_'�.- — _-- - ---- Date _J '2- S ' � L - - -- — <br />�Si9imlwc of installmg 9as �ilter) <br />Please arrange for someone to be present on the date oi requested inspection to provide access for <br />ihe inspection. <br />NLFRIGENANT CONTAINING PARTS OF THE SYSTEM THAT IS FIELD ERECTED SHALL E� I ESTED FOP LEAKS AT TEST PRESSURES NOT <br />L6SS 7 HAN THE LOWER OF THE DESIGN PRESSURES OR THE SETTING OF THE PRESSURE RELIEF OEVICES. THE DESIGN PRESSURE <br />�R TESTING SHALL 6E THOSE LISTED ON THc WNUENSING UNIT OR COMPRESSOR UNIT NAASE PLATE. (WAC 51 �42-1108) <br />`� Hard Copy - Job Site Pink Copy - Contractor White Copy - Inspector <br />r�wF�rn �sri �� <br />