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SNOHOMISH COUNTY PLANNING & DEVELOPMENT SERVICES <br /> GAS PIPING TEST AFFIDAVIT - <br /> (Only for use in Occupied Buildings) M4 T— <br /> Homeowner <br /> Homeowner �fre�A 4 �z a� G e-o M C G r-,e- G t <br /> Address 0– -7 g S LtJ t✓KILA `'91%3 Permit No. <br /> The gas piping system was tested at psi fora total _of minutes. <br /> WITNESSED BY <br /> (signature of occupant requesting gas service) (date) <br /> INSTALLED BY S 6Qs V /--/Z— <br /> (signatmo of installing gas fitter) (date) <br /> Please arrange for someone to be present on the date of requested inspection to provide access for the <br /> inspector. Tile white copy must be mailed to Snohomish County Planning & Development Services, <br /> M/S #604, 3000 Rockefeller Avenue, Everett WA 98201-4046 upon completion. <br /> White Copy— Mal Hard Copy—Job Site <br /> acr <br /> rovrm <br />