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CITY OF EVERETT <br />GAS PIPING TEST AFFIDAVIT <br />Homeowner, <br />Address 79 63 l c7 T) lq 6f S Permit No. J0/go <br />The gas piping system was tested st_,e4e0-'_psi for a total of ;�oo minutes. <br />WITNESSED BY <br />INSTALLED B <br />_J 23 <br />(signature o oc upa t requesting gas service) (ate <br />(signatur of installing gas fitter) date <br />Please arrange for someone to be present on the date of requested inspection to provide <br />access for the inspector. <br />Hard Copy -Job Site Pink Copy - Contractor White Copy - Inspector <br />