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� <br />� <br />CITY OF EVERETT <br />PIPING TEST AFFIDAVIT <br />\, <br />Owner _`1�6� L___S�UC_35_ — ---------- - <br />S� � c <br />Job Address Zq l�_ ZI_.- _��_.���(���_, V� (i _� � Z_01_ Permit No. X I_Z\\ -^J�1 ---- <br />�` - - — <br />� t; f' ���Up (,Q ��4�vc��>� <br />The refrigerant line / natural / LP / medical gas system (circle one) was tested at __ ___ __ psi for a <br />total of _ ___ ___ minutes�I <br />WITNESSED BY __(/�/G�—�_ _ — ____—____ <br />(Siqn;iluie of occupHnt reqursUng �as service� <br />INSTALLED BY _[�/i��L�____ � <br />(Signalurr, of in;talLng gas!Nc�) <br />Date //- Z� - / z <br />Date _//_ZC-/Z <br />Please arrange for someone to be present on the date of requested inspection to provide access ior <br />the inspection. <br />REFRIG[N�NT CONTAINING P�HiS OF TIiE SVST[M I11AT IS FIELD ERGCTED SIIALI BE TESTf_D FOR LFAKS AT T[SI PRFSSUIIES NOf <br />LFSS TH�N �fHE LOWFR OP THf UFSIGM PRESSUR[S OH ill[ SETTINi; OF 1 HL PRESSURf_ R[LIGF DEVICES. TH[ Df_SIGN PRESSURf <br />FUR T[STING SIIALL BL THOSG LISI ED ON TI1E COND6NSING UNIT OH CCPdPRLSSOR UNIT NAMC PLA�E (WAC SI �42ll00) <br />Hard Copy - Job Site Pink Copy - Coniractor White Copy - Inspector <br />��wi�tn �s�i �� <br />