Fillable City of Worcester Department of Public Works Contractor (City of Worcester)

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City of Worcester Department of Public Works Contractor (City of Worcester)

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The City of Worcester Department of Public Works Contractor (City of Worcester) form is 1 page long and contains:

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Country of origin: US
File type: PDF

U.S.A. forms for City of Worcester

BROWSE CITY OF WORCESTER (MA) FORMS

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City of Worcester
Department of Public Works
Contractor Information Update
General Information
Company Name:________________________________________________________ License Types
Container Company ___
Address Line 1:_________________________________________________________ Drain Layer ___
Driller ___
Address Line 2:_________________________________________________________ General Contractor ___
Restaurant ___
City, State, Zip Code:_____________________________________________________ Paver ___
Utility ___
Telephone: ( ) __________________________________ _____
Cell Phone: ( ) ________________________________________
Fax: ( ) _____________________________________________
E-Mail Address: _________________________________________
FID#: _____ - _____ - _____
Insurance and Surety Information
Name of Insurer:_________________________________ Insurance Amount:_________________________________
Insurance Certificate #: ___________________________ Insurance Expiration Date: ___________/______/________
Month Day Year
Name of Agent:__________________________________ _________________________________________________
Address:________________________________________ Telephone:( )_____________ Fax:( )______________
City/Town:_______________________________________ State: _____________________ Zip Code:______________
Type of Surety: Cash Bond Not Required
Surety Company: __________________________________________________________________________________
Surety Amount: __________________________________ Surety Expiration Date: ___________/______/___________
Month Day Year
Contact Information
Name of Competent Person:_________________________________________________________________________
(as defined by 520 CMR 7.02)
Name of Person Performing Excavation:________________________________________________________________
Mass Hoisting License #____________________________ License Grade:_________ Expiration Date:_____________
Name of Contact:_________________________________________________ Telephone: ( ) ___________________
E-Mail Address: ___________________________________________ ______ Primary Contact: Yes No
Name of Contact: ________________________________________________ Telephone: ( ) ___________________
E-Mail Address: _________________________________________________ Primary Contact: Yes
No
Return the completed form to: Department of Public Works and Parks
Permit Office
20 East Worcester Street
Worcester, MA 01604
or Fax completed form to: (508) 799-1426
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City of Worcester Department of Public Works Contractor (City of Worcester)

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Completed 10 February 2021

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