EOPSS-DFS

Fire Prevention Regulations 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

Appellant's Phone Number

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

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

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:

Applicable Section of the State Fire Code (527 CMR 1.00) that Fire Department cited in determination. 527 CMR 1.00, Section:(Required)

State the specific grounds and reasons for filing this Appeal.

Additional Materials / Documents / Photographs to be Submitted

Drop files here or

Max. file size: 50 MB.

Acknowledgements

I hereby swear and affirm that I am the Appellant or the legal representative of the Appellant and have the legal authority to file this appeal and/or represent the Appellant in this matter. (Please submit written documentation of such authorized representation.)

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.

I acknowledge that following the submission of this appeal, I will be contacted by Board staff on how to submit with the required $150.00 filing fee (made payable to the Commonwealth of Massachusetts) for the appeal. 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):

Submission Date(Required)