Applicant Registration Form
PERSONAL DETAILS
LOGIN DETAILS
OTHER DETAILS
LICENSE(S) DETAILS
ESTABLISHMENT DETAILS
DESIGNER DETAILS
INSTALLER DETAILS
PREVIEW
STEP 1- PERSONAL DETAILS
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Name
Address
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Street No.
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Street Name
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City
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State
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Zip
Contact
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Phone
Alt. Phone
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Email
Fax
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STEP 2 - LOGIN DETAILS
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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.
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Password
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Re-enter Password
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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, or UNLICENSED AGENT
as a CONTRACTOR
as an ESTABLISHMENT, RESTAURANT or FACILITY
as a SEPTIC DESIGNER
as a SEPTIC INSTALLER
as a SEPTIC INSPECTOR
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STEP 4- LICENSE(S) DETAILS
Business Name
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License Type
Select License Type
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License Number
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Expiration Date
Select date
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License Type
Select License Type
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License Number
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Expiration Date
Select date
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WORKER'S COMP DETAILS
Sole proprietor
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Insurance Company Name
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Policy Number
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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 homeowner doing all work myself. [No workers' comp. insurance required.]+
I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees.
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.]
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STEP 5- ESTABLISHMENT DETAILS
Address Does Not Appear in Drop-Down
Street Address / Owner
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Est. Name
DBA
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Street Name
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Map Block Lot
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Street Number
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Street Name
Map Block Lot
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Street Number
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City
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State
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Zip
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Telephone
Fax
Property Owner Details
Property Owner Name
Street Number
Street Name
City
State
Zip
Telephone
Business Owner Details
Same As Property Owner
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Business Owner Name
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Street Number
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Street Name
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City
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State
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Zip
Telephone
Email
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STEP 6- DESIGNER DETAILS
Designer Details
Same As Applicant
Septic Designer Name
Name of Company
Street Number
Street Name
City
State
Zip
Telephone
Email
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STEP 7- INSTALLER DETAILS
Installer Details
Same As Applicant
Septic Installer Name
Name of Company
Street Number
Street Name
City
State
Zip
Telephone
Email
Exp. Date
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