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Homeowner <br />CITY OF EVERETT <br />GAS PIPING TEST AFFIDAVIT <br />Address_ �OC.III� _ I`�� C Permit No. � �oZ LZ'�� <br />Tfieg�3-piping system was tested at S psi for a total of I�minutes. <br />i�n s� � � �Z i b� r� ��� �� o� w,��-rL <br />WITNESSED BY ` <br />(s <br />� �-=',`' �, -_ .- - <br />. / j ` t-z.-� ' ---- _ . <br />re ot occupant <br />ng gas service <br />/�� U � <br />(date) <br />INSTALLED BY ��CC�I ; /'��,�,/./W--- �� c� ��7.j <br />.� �signature of installing gas fitter) (date} <br />� � �! � s<v'i s ; 5��. <br />Please arrange (or someone to be presen`t on the date of requested inspection to provide <br />access for the inspector. <br />1�j Hard Copy - Job Site Pink Copy - Contractor White Copy - Inspector <br />