City of Greenacres
For Licensed Contractors Only
This inspection method is available temporarily as an option during the COVID-19 Emergency. This form
is for use of water heater replacements only (like for like). It does not cover installation of a tankless or
solar type water heater. Clear photos are required to verify minimum code compliance. Final inspections
may still be requested by the contractor or property owner.
Permit Number Subdivision or Plaza
Email completed form and photos to:
Contractor Information
Company Name Qualifier Name
Company Address City ST Zip
License Number Phone
I qualifier do hereby certify that the installation for the water heater
changeout installed at has been completed and performed in
accordance with the Florida Building Code. I understand that I may be randomly selected and contacted
for the arrangement of an inspection to verify the work performed is code compliant. I have attached
photographs that clearly depict the following:
Address written clearly on water heater
Water heater connections
Water heater disconnect switch or the electric service panel
Hot & cold water shut off valve
T/P relief valve
Drain pan (if required)
Note: Additional pictures may be required at the inspector’s discretion.
Signature of Qualifier Print Name:
Sworn to (or affirmed) and subscribed before me this day of 20
By (Name of person making statement).
Signature of Notary Public State of Florida
Personally, Known OR Produced Identification (Type of Identification)
(Notary Public Stamp)
click to sign
click to edit