Appeal Of An Inspector'S Decision Form - Commonwealth Of Massachusetts
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1Commonwealth of Massachusetts
Division of Professional Licensure
Board of State Examiners of Electricians
1000 Washington Street, Suite 710 Boston Massachusetts 02118-6100
APPEAL OF AN INSPECTOR’S DECISION
FEE - $86.00 (make checks out to “Commonwealth of Massachusetts”)
(1) APPELLENT INFORMATION (party appealing inspector’s decision)
NAME: ___________________________________ ADDRESS: _____________________________________________
CITY/TOWN: ____________________ STATE: ________ ZIP:__________________
TELEPHONE: ____________________ FAX: ____________________ EMAIL: ________________________________
___________________
LICENSE NUMBER (if applicable):
(2) REQUIRED INFORMATION
ADDRESS OF WORK SITE: _________________________________________________________________________
DATE OF INSPECTOR DECISION (Appeal must be within 10 days per M.G.L. c. 143, s. 3P): _____________________
APPLICABLE GENERAL LAW OR CMR AT ISSUE: ______________________________________________________
DECISION OF THE INSPECTOR: ____________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
IF ADDITIONAL SPACE IS REQUIRED, ATTACH PAGE(S) TO THIS FORM
(3) REASON FOR APPEAL
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
IF ADDITIONAL SPACE IS REQUIRED, ATTACH PAGE(S) TO THIS FORM
(4) INSPECTOR INFORMATION
INSPECTOR NAME: _______________________ CITY/TOWN: __________________ TELEPHONE: ______________
Send this form, fee, a copy of any permits, and a copy of the inspector’s decision (if in writing), to the Board office at the
above address. You also must send a copy of all submitted documents to the Inspector whose decision you are
appealing. This appeal will be entered in Board records 1 to 2 weeks after receipt of this completed form and required
fee. A notice of hearing will be sent to both parties scheduling the matter for the next available Board meeting.
I certify under pains and penalties of perjury that the information contained in this appeal form and accompanying
documents is true and correct to the best of my knowledge and that I have sent a copy of this information to the Inspector.
__________________________________________
__________________________________________
Signature of Appellant
Date
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