Commonwealth of Massachusetts
Division of Professional Licensure
Board of State Examiners of Plumbers and Gas Fitters
1000 Washington Street, Suite 710 • Boston • Massachusetts • 02118-6100
APPEAL OF AN INSPECTOR’S DECISION
FEE - $86.00 – MAKE CHECK PAYABLE TO THE COMMONWEALTH OF MASSACHUSETTS
APPELLANT INFORMATION
NAME: ADDRESS:
CITY/TOWN: STATE: ZIP: LICENSE NUMBER (if applicable):
TEL: FAX: EMAIL:
APPEAL SITE INFORMATION
SITE ADDRESS: CITY/TOWN:
DATE OF INSPECTOR DECISION (Appeal must be within 10 days per M.G.L. c. 142, s. 13):
APPLICABLE GENERAL LAW OR CMR:
DECISION OF THE INSPECTOR:
IF ADDITIONAL SPACE IS REQUIRED, ATTACH PAGE(S) TO THIS FORM
REASON FOR APPEAL
IF ADDITIONAL SPACE IS REQUIRED, ATTACH PAGE(S) TO THIS FORM
INSPECTOR INFORMATION
INSPECTOR NAME: TEL:
Send this form to the Board office at the above address, along with the fee, a copy of any permits, and a copy of the
inspector’s decision (if in writing). You also must send a copy of all submitted documents to the Inspector whose decision
you are appealing.
I certify under pains and penalties of perjury that the information contained in this appeal form and ac companying
documents is true and correct, to the best of my knowledge.
__________________________________________ ______________________________
SIGNATURE OF APPELLANT DATE
