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CITY OF EVERETT <br /> PIPING TEST AFFIDAVIT <br /> Owner J/'i'"�'= 5 �i�s'�T L /" %T , <br /> Job Address ���i% �����/, ,�,� ,.�� ,��,',-�!� j7 ,� ,? 9�s��/ Permit No. �O � /O ^ oo'� �' <br /> r <br /> The refrigera�line / natural / LP/ medical gas system (circle one) was tested at � `J psi for a <br /> total of 1 '� minute�s. <br /> WITNESSED BY ,�iJ CC z�.� _ Date / — /�/ 'O 3 <br /> i nature o oc pant requesting gas service <br /> INSTALLED BY > > ,� Date ���,-;�; <br /> Please arrange for someone to be present on the date of requested inspection to provide access for <br /> the inspection. <br /> REFRIGERANT CONTAINING PAHTS OF THE SYSTEM THAT IS FIELD ERECTED SHALL BE TESTED FOR LEAK AT TEST PRESSURES NOT <br /> FOR ESTINGHSHAOLW BE TOHOSE LDISTED ON THE CONDENSING UN TIOR COOMPRESSON UN T NAM PLATE.(WAC 51•4�2•S70B)PpESSURE <br /> Hard Copy—Job Site Pink Copy—Contractor White Copy— Inspector <br />