Applicant Registration Form

PERSONAL DETAILS

OTHER DETAILS

LICENSE(S) DETAILS

ESTABLISHMENT DETAILS

DESIGNER DETAILS

INSTALLER DETAILS

WORKER'S COMP DETAILS

PREVIEW

STEP 1- PERSONAL DETAILS

* Name

Address

* Street No.

* Street Name

* City

* State

* Zip

Contact

* Phone

Alt. Phone

* Email

Fax

STEP 2 - LOGIN DETAILS

*UserName

USE ONLY up to 20 alpha characters and numbers in your User Name and Password.
UNACCEPTABLE SPECIAL CHARACTERS include: these @ # $ % & * as well spaces, underscores, any punctuation, brackets or parentheses.

* Password

* Re-enter Password

Upload Photo

STEP 3- DETAILS

Instructions Please describe yourself using the checkbox 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, or OTHER (non-licensed) AGENT

as a CONTRACTOR

for an ESTABLISHMENT or RESTAURANT

Documents Required:

WORKER'S COMP DETAILS

STEP 4- LICENSE(S) DETAILS

Business Name

* License Type

* License Number

* Expiration Date

Select date

* License Type

* License Number

* Expiration Date

Select date

REMOVE

ADD NEW LICENSE TYPE

STEP 5- ESTABLISHMENT DETAILS

* Establishment Name

* Street Name

Map Block Lot

* Street Number

* Street Name

Map Block Lot

* Street Number

* City

* State

* Zip

* Telephone

Fax

Business Owner Details

* Business Owner Name

* Street Number

* Street Name

* City

* State

* Zip

Telephone

STEP 5- DESIGNER DETAILS

Preparer's Details Same As

Preparer Name

Street Number

Street Name

City

State

Zip

Telephone

STEP 6- INSTALLER DETAILS

Preparer's Details Same As

Preparer Name

Street Number

Street Name

City

State

Zip

Telephone

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