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� <br />J J 1 <br />CITY O� EVERETT <br />GAS PIPING TEST AFFIDAVIT <br />, �-. _ A J, _lI . <br />Homeawner „J/GUG7[ Lp,�uloUA t� i.�ts �ui/a"�S�u <br />Address J��.� �� �1'� S� Permit No. /il�—�� <br />The gas piping system was tested at a%O psi for a total of �� minutes. <br />WITNESSED BY <br />INSTALLED BY <br />(signature ot occupant requestiny gas service) <br />�� oa <br />(d ate <br />�(�/�e' <br />(date} <br />Please arrange for aomeone to be present on the date of requested inspeetion to provide <br />�, access for the inspector. <br />` Hard Copy - Job Site Pink Copy - Contractor White Copy - Inspector <br />