Plumber'S Affidavit Of Experience - Washington Department Of Labor And Industries
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1Department of Labor and Industries
PLUMBER’S AFFIDAVIT OF
PO Box 44470
EXPERIENCE
Olympia WA 98504-4470
360-902-5207
(Time frame cannot exceed 12 months per affidavit)
Please read this information before completing the affidavit form below:
•
There can be no errors, whiteouts, alterations, or additions on this form. You must submit the original.
•
Time frame cannot exceed 12 months per affidavit.
•
Washington hours will not be credited if you did not have a current plumber trainee certificate.
•
The supervising plumber’s name and certificate number are required.
•
The plumbing contractor, authorized contractor representative, or union representative must complete and sign the following
verification. Their signature must be notarized.
•
Work in the commercial/Journey Level category requires supervision in a one to one ratio (one Journey Level plumber to one
plumber trainee).
•
Work in the residential/specialty, domestic pump, and pump and irrigation category requires supervision in a two to one ratio (one
certified plumber to two plumber trainees).
I, ____________________________________________________________________ affirm and certify that
Print name of owner, authorized contractor representative, or approved training director
______________________________
______________________________ has worked in Washington as
Print name of trainee
Training certificate or Social Security Number
an employee of ___________________________________________
_____________________________
Print name of company or training program
UBI or license number.
performing plumbing work from _____________________________ to _____________________________
Month
Day
Year
Month
Day
Year
and that the work was performed under direct supervision of a Washington certified Journey Level or Specialty
plumber.
Print supervising plumber name
Print supervising plumber certificate number
The experience was gained in the category indicated below for the number of hours shown.
Hours
Category
Hours
Category
(01) Commercial
(03) Pump and irrigation
(02) Residential
(03A) Domestic well
I hereby certify that the statements on this affidavit are true and accurate and request that these hours be
credited to my plumbing training file.
Date
Print name of trainee
Signature of trainee/applicant
This section must be notarized.
I hereby certify that the statements on this affidavit are true and accurate.
Signature of owner, authorized contractor representative, or approved training director
Date
SUBSCRIBED AND SWORN TO BEFORE ME THIS DATE
MY COMMISSION EXPIRES ON
NOTARY PUBLIC IN AND FOR THE STATE OF
RESIDING AT
Notary signature and seal
F627-004-000 Affidavit of Experience 07-2013
RESET
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