Department of Labor and Industries PO Box Olympia WA lni

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					 Department of Labor and Industries
 PO Box 44540
 Olympia WA 98504-4540                                             REQUEST FOR PUBLIC RECORDS
 SHOC235@lni.wa.gov                                                 Prevailing Wage – Certified Payroll
 Fax #360-902-5300                                                                  RCW 42.56



      Date

      Name of person making request             Phone number         Name of person information to be sent to:
                                                ( )
      Address                                                        Address

      City                                      State      ZIP       City                              State ZIP

      Email


     I am requesting certified payroll records for the following:
      Project Title:
      Bid Date                                                         Contract Number:
      Contractor of Interest:
      License Number:                                                  UBI Number:
      Mailing Address
      Contact                                  Phone Number                          Fax Number
      Awarding Agency:
      Mailing Address
      Contact                                  Phone Number                          Fax Number
      Prime Contracter:
      License Number:                                                  UBI Number:
      Mailing Address
      Contact                                  Phone Number                          Fax Number

     I choose to inspect the records at no charge before selecting copies. □ Yes □ No

     I certify that I will not use the requested records for commercial purposes in the event that a list of
     individuals is included in the material provided, as per RCW 42.56.070(9). (This statute does not apply to
     lists of business.) The Department of Labor and Industries defines commercial as communication with the
     individuals named in the record for the record for the purpose of facilitating profit-expecting activity.


      Date              Name                                       Signature

     Photocopies may be charged at 15 cents per copy.

F700-141-000 certified payroll public disclosure request 04-2008                   RESET