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CITY OF EVERETT <br />GAS PiPING TEST AFFIDAVIT <br />Homeowner c:h.cr -/ /��(/li/ — —_ <br />Address %Z l�( s/+'�c � J. Permit No. %/n `l O,?0 <br />/ � <br />The gas piping system was tested at /'l psi for a total af�_minutes. <br />WITNESSED BY <br />INSTALLED BY <br />(signatu�e of occupant requestinp yas aervice) <br />�date <br />� 7 Z�U <br />(date <br />Please arrange for someone to be present on the date of requeated inspection to provide <br />access for the inspactor. <br />Hard Copy - Job Site Pink Copy - Contractor White Copy - Inspe�tor <br />