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CITY OF EVERETT <br />GAS PIPING TEST AFFIDAVIT <br />Homeowner <br />Address-//o I 17Ol-ALF S;? , fl eRe 11 tUi9P% Permit No.`hJ C1 0- ,6�� <br />The gas piping system was tested at 1:j psi fora total of- /-i�_minutes. <br />WITNESSED BY <br />INSTALLED BY <br />ignature of occupant r q e ling gas service) (date <br />(signature of insfalling 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 Site Pink Copy - Contractor White Copy - Inspector <br />