EOPSS-DFS

Automatic Sprinkler Appeals Board - Appeal Application

Appellant's Name

First Last

Appellant's Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

E-mail Address (for receiving hearing notices and Board correspondence)

Representative of Appellant (if any) and professional capacity (attorney / professional engineer, etc.)

Representative's Address (if different from Appellant)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Address of Property At Issue

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Appellant's Relationship to Building Involved (Owner / Occupant-Tenant, etc.)

Appellant is appealing a determination of the Head of the Fire Department from (insert fire department name below):

Date the determination (order of notice) was received by the Appellant:

Check Applicable Section of Mass. Law that Fire Department cited in determination(Required)

Provision of state sprinkler law that applies

Detailed statement or memo of the reasons for the relief requested. You should include specific details about the building such as, but not necessarily limited to: the building size, interior dimensions, building type/ classification, posted capacity, and existing fire safety features. You should give the specific reasons why you feel that the building should not be subject to the determination of the fire department. (If you wish to upload a memo, please use the next box.)

Additional Materials / Documents / Photographs to be Submitted (If your files exceed the max file size, please contact the Board for additional assistance.)

Drop files here or

Max. file size: 50 MB.

Acknowledgements

I acknowledge that whoever is aggrieved by the head of the fire department’s interpretation, order, requirements, direction or failure to act under the provisions of M.G.L. Chapter 148, Section 26A 1/2, 26G, 26G1/2 or 26H, shall within forty-five (45) days after the service of notice thereof, appeal such interpretation, order, requirement, direction or failure to act to the Automatic Sprinkler Appeals Board.

I acknowledge that I, the Appellant, or my authorized representative, has completed this appeal application form to the best my ability and submitted a copy of the Written Determination or Order of Notice issued by the Head of the Fire Department, and any additional supporting documentation for consideration to the Automatic Sprinkler Appeals Board through this virtual portal.

I acknowledge that following the submission of this appeal, I will be contacted by Board staff on how to submit the required $100.00 filing fee (made payable to the Commonwealth of Massachusetts). I further acknowledge that failure to submit the filing fee may result in the appeal being dismissed.

I further swear and affirm that I have served a copy of this appeal, and all documents included with this appeal to the Head of the Fire Department.

Submitted By (Name):