Get Gas Test Affidavit 2013-2024

Gas Integrity Test Turn-On Affidavit This certifies that the gas piping in the building indicated below has successfully passed a leakage test as prescribed by the local authority having jurisdiction. Building Address / City or Town / Zip Code Complete All Sections That Apply Blue Card No. Lockable valves and test ports installed / exist at the base of each riser. It is also certified that in the affected area s All areas containing gas utilization equipment e.g. boiler room laundry room have been inspected and that the equipment gas valves have been closed. All apartments containing gas appliances have been inspected and the appliance valves have been closed. All open-ended valves stubs test connections purge connections or any other piping or fittings which could be left open have been closed gas tight with a threaded plug or cap. For premises which have meters in the apartments the meter valves have been left open so that the integrity test is complete up to the In addition I accept responsibility for the gas-in of any end of use equipment or appliances not gassed-in by Con Edison and identified above for turn-on. YES Plumbing Contractor Company Name / Address / Telephone Plumber s Signature / License / SEAL/ Date Rev. 11/2013. YES NO Circle One Gas Turn-On requested for the following equipment Specify below CONTACT INFORMATION FOR IMMEDIATE BUILDING ACCESS PHONE RISER LOCATION GAS END USE e*g* Cooking Heating Hot Water Dryer etc METER LOCATION NO. OF APTS Location 1 Contractor to Check Appropriate Corrective Condition I have repaired and tested Leak at gas equipment specify unit or equipment Control Valve Pilot Valve Appliance Valve Hood Draft Appliance Regulator Flue Connection Other Specify and provide details for above items checked end of use equipment in affected apartments or areas. YES NO Circle One Gas Turn-On requested for the following equipment Specify below CONTACT INFORMATION FOR IMMEDIATE BUILDING ACCESS PHONE RISER LOCATION GAS END USE e*g* Cooking Heating Hot Water Dryer etc METER LOCATION NO. OF APTS Location 1 Contractor to Check Appropriate Corrective Condition I have repaired and tested Leak at gas equipment specify unit or equipment Control Valve Pilot Valve Appliance Valve Hood Draft Appliance Regulator Flue Connection Other Specify and provide details for above items checked end of use equipment in affected apartments or areas. .