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, � <br /> CITY OF EVERETT ' <br /> GA5 PIPING TEST AFFIDAVIT <br /> Homeowner �f'LC—�l 1�C1--� <br /> n n `�Q.. �iJ i Permit No. mc�-o�4 <br /> Address ,S� ,7,.c ' LUrr ` <br /> The gas piping system was tested at�Ps� for a total of�_minutes. <br /> WITNESSED BY ��� �X) <br /> signature c+f o pant requesting gas service) (date <br /> INSTALLED BY —�J�� I <br /> ' (sign�ture of ' Iling gas fitter) (date I <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 /> � <br />