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CITY OF EVERE�i'T' <br /> GAS PIPING TEST AFFIDAVlT <br /> Homeowner � �_,�,,« ��-� J , � �� � �� <br /> Address 1�? C� c���� I G i l. �J� S � Permit No. ���( �/c ��' t'�+j � <br /> � <br /> The gas piping system was tested at i � psi for a total of � � minutes. <br /> ��,t�.t�1 l ; � �— ��� v� �— <br /> VVITPlESSED BY � <br /> (signature of occupan requesting gas service; (date <br /> �; �;�; , <br /> INSTALLEDBY % ,'`�=:'..�� v��'l.�'�u L �� ���� <br /> (signature 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 Sfte Pink Copy - Contractor White Copy - Inspector <br />