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CITY OF rVERETT <br />; GAS PIPING TEST AFFIDAVIT <br />Homeowner �%�',f <% ���U���l/ <br />Address � 7 G'�� r�U,�-�(•'r� %�"� �--���� Permit No. �—OoZ,S� <br />The gas piping system was tested at�psi for a totai of � minutes. <br />WITNESSED Bl <br />INSTALLED BY <br />� <br />(date <br />-�.I�� <br />(date <br />Piease arrange for someone to be present on the date of requested ii�spection to provide <br />access for the inspector. <br />Hard Copy - Job Site Pink Copy - Contractor White Copy - Inspector <br />