190 BRIDGE STREET, UNIT 5202 WATER & SEWER SUBMETER CERTIFICATE IVIASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH
SUBMETERING OF WATER AND SEWER CERTIFICATION FORM
In accordance with M.G.L.c. 186, § 22 and 105 CMR 410.000:krinimun?Standartis of'Filness fin-Human Habitation,State
Sanitary Cade, Cha Ater 11(the-Hotlsin ,Code" ), the followin�dwelling unit is eligible for submetering,water and sewer.
PROPERTY INFORMATION
Address: 2r v. Unit# #Of units in bldg.
City/Town: &Iem MA M A Zi Code:
EQUIPMENT INSTALLATION INFORMATION
105 CMR 410.130(C) requires the installation of water conservation devices prior to a dwelling unit becoming eligible for
submetering for water and/or sewer services. The devices must meet the following specifications:
Showerheads with maximum flow torte not to exceed 2.5 gallons per minute(gpm)
Faucets with maximum flow rate not to exceed 2.2 gallons per minute(gpm)
Ultra-low:flush toilets not to exceed 1.6 gallons per flush(gpl)
The submetering;equipment used to measure the quantity of water used for each dwelling unit and common area must
meet the standards of accuracy and testing of the American Water Works Association or similar accredited association.
A Massachusetts licensed plumber must install the toilets and submetering equipment.
Submetering equipment information:
Manufacturer Model#
LICENSED PLUMBER CERTIFICATION
f1lill"a
that(check all that apply):
ave installed or inspected the submetering equipment listed above and have determined that they meet accepted pk inibing standards.
ve installed or inspected all(lie toilets in this unit and have determined that they meet accepted plumbing standards.
The plumbing permit issued by the city/town,if required.is attached.
This dwelling unit is connected directly to a meter installed by a water company and,in accordance with M.GJ .c. 186,§22(p),does
not require the installation of a submeter.
Licensed Plumber's Name Plumber'Signature License## Date
OWNER CERTIFICATION
I certify that:
(1)This dwelling unit is eligible for submetering;of water and/or sewer usage in accordance with the water submetering law
(MGL c. 186,§22).
(2)All showerheads,faucets and toilets in this dwelling unit meet the conservation standards specified above.
(3)The water submeter(if present)measuring the use of water in this dwelling unit was installed by a licensed plumber and
complies with the standards of accuracy and testing required by the water submetering law(M.G.L. c. 186, § 22).
(4)The water meter or submeter measures the water usage exclusive to this unit.
(5) 1 will provide to the tenants of this dwelling unit,prior to occupancy,a written rental agreement that clearly provides for the
separate charging of water and/or sewer service,and a copy of this certification form.
(6) All information included on this certification is true and accurate to the best of my knowledge.
THIS FORM MUST BE FILED WITH THE LO E LTH DEPARTMENT PRIOR TO INITIATING SUBMETERING
Signed under the pains and penalties of pet jury, r
fi 3 "�' �`
t"
Name of Owner Si mat of caner
!lie propetty has been transferred to the owier above and the unit remains in compliance with the requirements or Al G 1_c
Date Subtn o th
Department:
Prior Olvicrs Signature Date
CITY OF SALEM
BOARD OF HEALTH
410-23-Submetering of Water and Sewer Certification Fornr 5-12-23