Department of Labor and Industries Asbestos Certification Program PO Box 44614 Olympia WA 98504-4614
APPLICATION FOR ASBESTOS CONTRACTOR CERTIFICATION
Account ID or UBI Certification No. Contractor Registration # Email address FAX number ( ) Expiration date Email address
Please PRINT IN INK or TYPE. Return the NOTARIZED ORIGINAL ONLY to ASBESTOS CERTIFICATION PROGRAM. This application must be COMPLETE or it will be returned. Allow 21 days to process. Firm name (Business name used in Washington as it appears on your contractor registration) Mailing address City Contact person D.B.A./ Doing Business as: Mailing address (if different than address above) City Contact person State ZIP+4 Telephone number State Telephone number ( ) URL ZIP+4
CERTIFIED ASBESTOS SUPERVISOR FOR COMPANY PROJECTS Attach list if more than one supervisor sharing this duty.
Attach a separate list of all asbestos abatement projects undertaken during the 12 months immediately preceding this application. Please include 1) Start date 2) Project name 3) Location 4) Description of project. Attach a separate list of any asbestos related enforcement action taken against applicant during the 12 months immediately preceding this application. Actions currently under appeal need not be listed. Please include 1) Action date 2) Agency 3) Regulation cited. The fee for this certificate is $1,000 per year. Upon approval, your initial certificate may be valid for less than a year. Calculate the fee at $83.33 per month or any partial month as an entire month for the purpose of calculating the whole fee. FULL EXPLANATION ON REVERSE SIDE.
Application Type Application date Expiration date Number of months (11 max) Total Fee
SUBSCRIBED AND SWORN TO BEFORE ME this date Notary Public Residing at My Commission Expires
I hereby apply for a Washington Asbestos Contractor Certificate, as described in Washington Administrative Code (WAC) 296-65-017. I have read, understand and agree to comply with all federal, state and local asbestos regulations. I understand violation of these regulations could constitute grounds for suspension or revocation of this certificate. My asbestos abatement contractor certification is not and was never suspended or revoked by any local, state or federal agency. I hereby certify that the statements on this application are true and accurate to the best of my knowledge. (See chapter 18.106 Revised Code of Washington (RCW) for false statement or material misrepresentations.)
Date Principal owner's signature in ink
For L&I use only
Send one copy of this application to the address above and keep a copy for your file. F413-007-000 app asbestos contractor cert 01-2006
Expiration date Check # Date mailed
EXPIRATION DATE FOR YOUR ASBESTOS CONTRACTOR CERTIFICATE and PRORATING THE FEE Asbestos contractor certifications cannot be granted for more than one year and must be set to expire at the same time as your contractor registration. If your contractor registration is expiring more than 12 months from now we will still set your asbestos contractor registration to the same date of the year, but no more than 12 months from the current date. (For example, if we were processing your application on January 12, 2006, and your contractor registration expiration date were July 22, 2007, your asbestos contractor certification will expire July 22, 2006.) This most commonly effects new applications, but may effect renewals if your registration expiration date has changed. If you certificate will be granted for less than a full year, the $1000 annual fee can be prorated. The prorating is based on the number of months or partial months that will be covered by the certificate. (For the above example, the period from January 12, 2006, to July 22, 2006, is counted as 7 months. There six full months up to July 12 and a partial month completing the period to July 22.) The prorated fee is $83.33 per month WAC 296-65-030 METHODS OF COMPLIANCE STATES IN PART... (1) Before submitting a bid or working on an asbestos abatement project, any person or individual shall obtain an asbestos contractor certificate as provided in WAC 296-65-017, and shall have in its employ at least one certified asbestos supervisor responsible for supervising all asbestos projects undertaken by the contractor. (2) A certified asbestos supervisor will not be required on projects involving less than three square feet or three linear feet of asbestos-containing material unless the surface area of the area is greater than three square feet. WAC 296-65-050 DENIAL, SUSPENSION, AND REVOCATION OF CERTIFICATES STATES IN PART... (1) The department may deny, suspend, or revoke a certificate for failure of the holder to comply with any requirement of this chapter or any applicable health and safety standards and regulations. (2) In addition to any civil penalty imposed under WAC 296-62-07707 and 296-65-030, the department may suspend or revoke any certificate issued under this chapter for a period of not less than six months upon the following grounds: (a) The certificate was obtained through error or fraud; or, (b) The holder thereof is judged to be incompetent to carry out the work for which the certificate was issued.