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PICKENS COUNTY PLANNING & DEVELOPMENT 1266 East Church Street, Suite 136, Jasper, GA 30143 Phone [PHONE REDACTED] Email: [EMAIL REDACTED] Fax [PHONE REDACTED] SUBCONTRACTOR AFFIDAVIT Building Permit Subdivision/Lot # Property Owner’s Name: Job Site Address: City State Zip Print Name Signature (Required) Date Mailing Address City State Zip Current Phone Number (Required) This is to certify that I am responsible for the Plumbing Mechanical Please indicate below the type of State License you hold and are using for this job Master Plumber Class I (Restricted to S/F. I level duplex and commercial up to 10,000 sq. ft.) Master Plumber Class E (Unrestricted) Conditioned Air Contractor Class I (Restricted to 60,000 BTU cooling and 175,000 BTU heating) Conditioned Air Contractor Class H (Unrestricted) A COPY OF YOUR STATE & BUSINESS LICENSE IS REQUIRED WITH THIS FORM AFFIDAVITS MUST BE SUBMITTED PRIOR TO ROUGH INSPECTION REQUESTS Plumbing/HVAC Contractor's Statement: The service equipment for the above referenced job location has been installed in accordance with all applicable state codes and county ordinances. In the event of any change in my status on this installation, I understand that I will be held responsible for this job until Planning and Development has been notified in writing of any changes. This is to certify that I am responsible for the plumbing and/or HVAC service on the above permit. Signature: Date: Please Print Name: County Business License Registered With: Business License Number: Expiration Date: State License Number: Expiration Date: Company Name: Company Street Address: City, State, Zip Code: Phone: Updated 2/15/2023