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�IA'" <br />��� <br />CITY OF EVERETT <br />GAS PIPING TEST AFFIDAVlT <br />Homeowner -- <br />Address � J�) � C' l`� r I l 7 _Permit No.� �•�� �"«' <br />- � .�- <br />The yas piping syster� was tested at_, �`� psi for a total of �� minutes. <br />S'VITPJESSED BY —J-1 <br />(signalure of occupant requesting gas service) (date) <br />INSTALLED BY <br />sigriature <br />�LF: <br />�� �� , <br />(date) <br />Pl��ase arrange for someone to be present on the date of requested inspection to provide <br />,,cr.ess tor the inspector. <br />Hard Copy - Job Site Pink Copy - Contractor White Copy - Inspector <br />71 <br />