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ti. S <br /> CITY OF EVERETT <br /> GAS PIPING TEST AFFIDAVIT <br /> Homeowner �s._.._�� ,J_p <br /> Addross � ��S S*�v�/' �l�- �`-" • P�rmit No.�l� <br /> �_ osi for a total of �� minutes. <br /> i he gas pipinp syatem w�s tosted �t / <br /> �- J� �r <br /> WITNESSED BY date <br /> (s n�turs ccu t request np qas serv ce) ( <br /> I'NSTALLED BY 'Ja e � <br /> ipnature of installinp p�� tter) ( <br /> Please arranye for someone to be present on the d�te of requested inspection to provide <br /> access for the inapector. <br /> Hard Copy - Job Site Pink Copy - Contractor Whits Copy - �nspector <br />