Certificate of Compliance

Exemption Form

for the

Inefficient Plumbing Fixtures Replacement Plan Ordinance

The following transaction or types of real property are exempt from compliance with the requirements of the Inefficient

Plumbing Fixtures Replacement Plan Ordinance.

Please check the applicable exemption:

 Any real property in unincorporated DeKalb County containing a structure that was constructed after January 1,

1993;

 Any real property that is being advertised for foreclosure;

 Any qualifying property that will not be inhabited but instead will be demolished after sale provided that prior to

demolition the purchaser shall not be allowed to obtain water service for the qualifying property unless such water

service is solely for demolition or construction related purposes;

 Any qualifying property that is sold or conveyed between spouses, or between parents and their children, including

conveyances during the administration of the estate of such spouse, parent, or child;

 Any qualifying property that, because of its architectural or historic restrictions, plumbing configurations, and/or

drainage system configurations, would cause the owner to suffer extreme economic hardship as defined in the

Ordinance; or

 Any real property in incorporated DeKalb County.

_________________________________________________________________ _____________________________

(Please Print) Applicant’s Last Name First Name MI Contact Phone Number

_________________________________________________________________________________________________

Service Address City State Zip Code

I, ________________________________________ pursuant to the laws of the State of Georgia assert under

(Owner’s Name)

penalty of perjury, that the service address listed above is exempt from compliance with the Inefficient Plumbing

Fixtures Replacement Plan Ordinance. I have attached documentation to prove that this property is exempt from

compliance.

__________________________________________________________ ___________________________________

Owner’s Signature Date

Revised: July 1, 2008