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CITY OF EVERETT <br /> PIPING TEST AFFIDAVIT � <br /> O�vner �—.a:l ":�!� 1�,C.v>__ — ----- <br /> Job Address �—=___' .� ��'�^;;.•'� ''�:% Permil No. '�.=�: %� � C.::a <br /> The retrigerant line / natural / LP / medical gas system (circle one) was tested at ,� . psi lor a <br /> total of ��i. minutes. <br /> VJITNESSED BY Date �� �� ��.. <br /> �: - - t� <br /> ignature o _occupant requi�sting gas serv�ce <br /> INSTALLED BY � �t-- Date �, � �i c�, i `" <br /> ,\�v'..•:��1 .�li�^'„ /�/`�� <br /> i i i � <br /> Piease arrange for someone to be present on the date of requested inspection to provide access tor <br /> the inspection. <br /> REf f71GERANT CO�JT-�ItJI1vG PARTS OF THE SYSTEt.1 THAT IS FlELD EHECtED SH�LL U[tESTED FOR LEAH AT T EST PRESSUHtS IJOT <br /> LE55 7�+aN THE LOW[R OF iHE D[SIGN PRESSURES OR TME SETTING OF THC PRESSURE RELIEP DEVICES. THE DESIGh PRESSURE <br /> FOR TESTING SHALL BE THOSE LISTED ON THE COND[NSIhG UNIT OR COt.�PRES50R UNIT N�IdEPLATF.IWAC 51�a2�1108) <br /> W� Hard Copy -Job Site Pink Copy- Contractor White Copy- Inspecror <br />