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*This Affidavit must be filled out completely or it will not be accepted. UNDERGROUND/SLAB PLUMBING AFFIDAVIT (For GA Licensed Plumbing Contractors Only) Date Plumbing Company Name Business Address Street City State Zip Business Telephone Cell # Plumbing License Holder Name Georgia State Plumbers License Business Telephone # City or County Issuing Business License (GA only) Business License # Expiration Date Subdivision: Lot # Address of Permitted Work: City Zip Permit # Name of Builder/Owner (Print): Note: This affidavit is for the sewer/septic line, underground water line, and /or plumbing in the slab as indicated below in lieu of an inspection. Sewer/Septic Line Water Line Plumbing in Slab I understand that it is my responsibility to insure that the installation as indicated above shall be installed in accordance with the current adopted Georgia State Plumbing Code and ordinances adopted by Gordon County. I hereby agree to indemnify Gordon County and its inspectors from any liability for damages, loss of property or costs due to improper installation. Signature Please Print Name Date SIGN