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Get MA Application for Permit to Perform Electrical Work 2007-2022

required by law. By my signature below, I hereby waive this requirement. I am the (check one) Owner/Agent PERMIT FEE: $ Signature Telephone No. (If applicable, enter “exempt” in the license number line.) Signature The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers’ Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legib.

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