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� <br />r <br />CITY OF EVERETT <br />GAS PIPING TEST AFFIDAVIT <br />I I r, m eow n e r_______�J <br />nddress� � r z .�--T��� <br />L �S �7� Permit No. � d�c�� O/ �+ <br />rtr��r{�Pgsystem was tested at���_L_Pgi br a total ol�[�'__minutes. <br />�:r'Y�7 C /Z �'L-- SJ ' <br />�� �%/ _ � �' � ' <br />��'i'tll SSFU f3Y � <br />( ignature of occupant requesting gas aervice) (date <br />��r ! AI LED �Y <br />,. � ,� <br />l '�� <br />(slgnature ins alling gas <br />J �`' � <br />(date <br />!� ase arrange for someone to be present on the date of requesled inspection to provide <br />�� �:ess br the inspector. <br />White Copy - Inspector'� "t� <br />`�� <br />Hard Copy - Job Site Pink Copy - Contractor <br />