Fillable Printable Form 101-009-000
Fillable Printable Form 101-009-000
Form 101-009-000
F101-009-000 Request for Public Records 03-2013
Department of Labor and Industries
Public Records Unit
PO Box 44632
Olympia WA 98504-4632
Questions? Call 360-902-5556
Request for Public Records
Email request to: PublicR[email protected]
Or
Fax request to: 360-902-5529
Requestor Information:
* Required field
Representing/On behalf of*:
Requestor name*:
Company name:
UBI #:
Mailing address:
City:
State:
Zip code:
Phone number*:
Fax number:
Email:
Requesting records on:
Workplace Safety and Inspection records
Company name:
UBI #:
Date of Incident:
Inspection #:
Was there a fatality?
Yes No
Is this in litigation?
Yes No
Are you appealing?
Yes No
Date of appeal hearing:
I need the complete inspection file.
I need the citation(s) only.
I need a copy of the complaint(s) only.
I need (other):
Construction Trades records
Contractor Registration
Plumber Certification
Electrical License/Permit
Elevator License/Inspection
Company name & UBI #:
Description of records you need:
Employment Standards Wage Complaint
(such as wage & overtime)
Prevailing Wage Complaint
Company name:
UBI #:
Approximate date:
DOSH Discrimination Complaint
(for reporting a hazard)
Industrial Insurance Discrimination Complaint
(for filing a claim)
Company name/Complainant name:
UBI #/Complaint #:
Approximate date:
Employer Audit Records
Fraud Investigation Records
Company name/Injured Worker name:
UBI #/Claim #:
Approximate date:
Other records
(Give a brief description of the records you need.)
I chose to inspect the records at no charge before selecting paper copies. Yes No
Please note - the review of the records will be held at L&I’s main office in Tumwater. Photocopies may be charged at 15 cents
per copy.
By signing below 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 businesses.) The
Department of Labor and Industries defines commercial purpose as communication with the individuals named in the record
for the purpose of facilitating profit-expecting activity.
Date
Name (please print)
Signature
RESET
