en-USLIBI-613L REV 10-18 (Page 1 of 1)en-USAuxiliary aids and services are available upon request to individuals with disabilities.en-USEqual Opportunity Employer/Program en-USFOR L&I USE ONLYen-US Cert #:en-US Date: en-USFOR L&Ien-USUSE ONLYen-USFiling en-USRequirements en-USLead en-USOccupationen-USSupervisoren-USen-USContractoren-USInformationen-USType ofen-USApplicationen-USLEAD CONTRACTOR CERTIFICATION APPLICATIONen-USPLEASE TYPE OR PRINT NEATLY IN INKen-USen-US en-USFEE SCHEDULE: en-USen-USen-USen-USen-USen-USen-USen-USen-USen-USCommonwealth of Pennsylvaniaen-USen-USen-USPA Department of Labor & Industryen-USen-USen-USen-USen-USen-USen-USSignatureen-USInitial City State Zip Code en-USen-USplease submit a request to update the company information on company letterhead. en-USen-USen-USBates #:en-USen-US en-USen-UStraineden-US and en-USen-UScen-USen-USen-USen-USen-USen-USen-US): en-US en-USen-US DEPARTMENT OF LABOR & INDUSTRY en-USBUREAU OF OCCUPATIONAL & INDUSTRIAL SAFETY American LegalNet, Inc. www.FormsWorkFlow.com