Applicant Registration Form
PERSONAL DETAILS
LOGIN DETAILS
OTHER DETAILS
LICENSE(S) DETAILS
ESTABLISHMENT DETAILS
DESIGNER DETAILS
INSTALLER DETAILS
Well driller details
Trash Haulers details
Pumper Haulers details
PREVIEW
STEP 1- PERSONAL DETAILS
*
Name
Address
*
Street No.
*
Street Name
*
City
*
State
*
Zip
Contact
*
Phone
Alt. Phone
*
Email
Fax
Exit
Next
STEP 2 - LOGIN DETAILS
*
UserName
Use only alpha characters and numbers. Do not use spaces, underscores, punctuations or special characters like ' , /, \ , * in the User Name or the password. The name should not exceed 20 characters.
*
Password
*
Re-enter Password
Upload Photo
Browse
Previous
Next
STEP 3- DETAILS
Instructions
Please describe yourself using the checkboxes below.
(Check all that apply.)
As you click, new sections will be added to this registration form.
Any information that you register with now will automatically flow into all applicable forms in the future.
I am applying for permits/licences:
as a HOMEOWNER, TENANT,REAL ESTATE AGENT , or UNLICENSED AGENT
as a CONTRACTOR
as an ESTABLISHMENT, RESTAURANT or FACILITY
as a SEPTIC DESIGNER
as a SEPTIC INSTALLER
as a SEPTIC INSPECTOR
as an INSTALLER (other than septic )
as a WELL DRILLER
as a TRASH HAULERS
as a PUMPER HAULERS
I am a CONSULTANT / REPRESENTATIVE (for planning, conservation and zoning)
I am an ENGINEER
I am a SURVEYOR
Previous
Next
STEP 4- LICENSE(S) DETAILS
Business Name
*
License Type
Select License Type
*
License Number
*
Expiration Date
Select date
*
License Type
Select License Type
*
License Number
*
Expiration Date
Select date
REMOVE
ADD NEW LICENSE TYPE
WORKER'S COMP DETAILS
Sole proprietor
*
Insurance Company Name
*
Policy Number
*
Policy Expiration Date
Select date
Are you an employer? Check the appropriate box
I am a employer with
employees (full and/or part-time).*
I am a sole proprietor or partnership and have no employees working for me in any capacity. [No worker's comp. insurance required.]
I am a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have worker's comp. insurance.++
We are a corporation and its officers have exercised their right of exemption per MGL c. 152, ß 1(4) and we have no employees. [No worker's comp. insurance required.]
Uncheck
Previous
Next
STEP 5- ESTABLISHMENT DETAILS
Address Does Not Appear in Drop-Down
Street Address / Owner
*
Est. Name/DBA
*
Street Name
*
Map Block Lot
*
Street Number
*
Street Name
Map Block Lot
*
Street Number
*
City
*
State
*
Zip
*
Telephone
Fax
Property Owner Details
Property Owner Name
Street Number
Street Name
City
State
Zip
Telephone
Business Owner Details
Same As Property Owner
*
Business Owner Name
*
Street Number
*
Street Name
*
City
*
State
*
Zip
Telephone
Email
Previous
Next
STEP 6- DESIGNER DETAILS
Same as Applicant
Preparer Name
Street Number
Street Name
City
State
Zip
Telephone
Email
Previous
Next
STEP 7- INSTALLER DETAILS
Same as Applicant
Preparer Name
Street Number
Street Name
City
State
Zip
Telephone
Email
Previous
Next
STEP 8- Well Driller
*
Well Drilling Company Name
*
Well Driller Certification Number
*
Expiration Date
Select date
Previous
Next
STEP 9- Trash Haulers
*
Trash Haulers Company Name
*
Trash Haulers Certification Number
*
Expiration Date
Select date
Previous
Next
STEP 10- Pumper Haulers
*
Pumper Haulers Company Name
*
Pumper Haulers Certification Number
*
Expiration Date
Select date
Previous
Next
Previous
Submit
Please Wait..
×
Remove License
Are you sure you want to remove this license type?