Reliance Row water and sewer submetering certification forms MASSACHUSETTS 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:Minimum Standards of Fitness for Human Habitation
(State Sanitary Code Chapter II),the following dwelling unit is eligible for the imposition on the tenants of a charge for
water and/or sewer service.
PROPERTY INFORMATION
Address: Reliance Row Unit# 1 #Of units in bldg. 11
City/Town: Salem MA Zip Code: 01970
EQUIPMENT INSTALLATION INFORMATION
105 CMR 410.000 requires the installation of water conservation devices prior to a dwelling unit becoming eligible for the
imposition on tenants of a charge for water and/or sewer. The devices must meet the following specifications:
Showerheads with maximum flow rate not to exceed 2 'gallons per minute(2.5 gpm)
Faucets with maximum flow rate not to exceed 2 Z/'o gallons per minute(2.2 gpm)
Ultra-low flush water closets toilets not to exceed 1 6no
(toilets) gallons per flush(1.6 gpf)
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 licensed plumber must install the water closets and submetering equipment.
Submetering equipment information: Norgas Metering Technologies Inc Versamag Poly
Manufacturer Model#
Licensed Plumber Certification ��
Paul LeGault 19756
Print Name of Plumber License# Date
I certify that(check all that apply):
®I have installed the submetering equipment listed above in accordance with accepted plumbing standards.
❑ I have installed one or more water closets not exceeding 1.6 gallons per flush.
®Determined that existing water closets do not exceed 1.6 gallons per flush.
❑The plumbing permit issued by the city/town, if required, is attached.
❑Dwelling unit is connected directly to a meter installed by a water company and, in accordance with
M.G.L . c. 186, §22(p),does not require the installation of a submeter.
Signed under the pains and penalties of perjury, Signature of Licensed Plumber
Property Owner Certification
I certify that:(1)This dwelling unit is eligible for the imposition on the tenants of a charge for water and/or sewer usage
in accordance with the water submetering law(MGL c. 186, §22); (2)All showerheads, faucets, and water closets in this
dwelling unit are water conservation devices that meet the standards specified above; (3)The water submeter measuring
the use of water in the dwelling unit was installed by a licensed plumber and is in compliance with the standards
specified above, or the water meter measuring the use of water in this dwelling unit was installed by a"water company"
as defined in M.G.L. c. 186, § 22; (4)The water meter or submeter measures the water usage exclusive to this unit;(5)I
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)That all information included on
this certification is true and accurate to the best of my knowledge.
Sig W&i �u �? 11,2 0--ri
ned der the pains and penalties of perjury,
1L
9 Qk -UVT $6
Print Name of Owner Si nature of Owner /HiEGEIVED
Date
The property has been transferred to owner above and the unit Received SEP 18 2020
remains in compliance with the requirements of M.G.L. c. 186, §22 Date: b� BOH:
*THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBQTLEM
BOARD OF HEALTH
MDPH-CSP Submetering Form,Rev 11-4-16
MASSACHUSETTS 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:Minimum Standards of Fitness for Human Habitation
(State Sanitary Code Chapter II),the following dwelling unit is eligible for the imposition on the tenants of a charge for
water and/or sewer service.
PROPERTY INFORMATION
Address: Reliance Row Unit# 2 #Of units in bldg. 11
City/Town: Salem MA Zip Code: 01970
EQUIPMENT INSTALLATION INFORMATION
105 CMR 410.000 requires the installation of water conservation devices prior to a dwelling unit becoming eligible for the
imposition on tenants of a charge for water and/or sewer. The devices must meet the following specifications:
Showerheads with maximum flow rate not to exceed 2 v�gallons per minute(2.5 gpm)
Faucets with maximum flow rate not to exceed 2 z/10 gallons per minute(2.2 gpm)
Ultra-low flush water closets(toilets)not to exceed 1 6/10 gallons per flush(1.6 gpf)
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 licensed plumber must install the water closets and submetering equipment.
Submetering equipment information: Norgas Metering Technologies Inc Versamag Poly
Manufacturer Model#
Licensed Plumber Certification ® An
Paul LeGault 19756 b AUG L
Print Name of Plumber License# Date
I certify that(check all that apply):
®I have installed the submetering equipment listed above in accordance with accepted plumbing standards.
❑ I have installed one or more water closets not exceeding 1.6 gallons per flush.
®Determined that existing water closets do not exceed 1.6 gallons per flush.
❑ The plumbing permit issued by the city/town,if required, is attached.
❑Dwelling unit is connected directly to a meter installed by a water company and, in accordance with
M.G.L. c. 186, § 22(p),does not require the installation of a submeter. s
Signed under the pains and penalties of perjury,
�a— R A --
Si mature of Licensed Plumber
Property Owner Certification
I certify that: (1)This dwelling unit is eligible for the imposition on the tenants of a charge for water and/or sewer usage
in accordance with the water submetering law(MGL c. 186, §22);(2)All showerheads, faucets,and water closets in this
dwelling unit are water conservation devices that meet the standards specified above;(3)The water submeter measuring
the use of water in the dwelling unit was installed by a licensed plumber and is in compliance with the standards
specified above, or the water meter measuring the use of water in this dwelling unit was installed by a"water company"
as defined in 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)That all information included on
this certification is true and accurate to the best of my knowledge.
Signed under the pains and enalties of perjury,
L P21d
Print Name of Owner Si nature of Owne
Date L
The property has been transferred to owner above and the unit Received
remains in compliance with the requirements of M.G.L. c. 186, 22 Date: by BOH:
*THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBMETERING
CITY OF SALEM
MDPH-CSP Submetering Form,Rev 11-4-16 BOARD OF HEALTH
MASSACHUSETTS 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:Minimum Standards of Fitness for Human Habitation
(State Sanitary Code Chapter 11),the following dwelling unit is eligible for the imposition on the tenants of a charge for
water and/or sewer service.
PROPERTY INFORMATION
Address: Reliance Row Unit# 3 #Of units in bld . 11
City/Town: Salem MA Zip Code: 01970
EQUIPMENT INSTALLATION INFORMATION
105 CMR 410.000 requires the installation of water conservation devices prior to a dwelling unit becoming eligible for the
imposition on tenants of a charge for water and/or sewer. The devices must meet the following specifications:
Showerheads with maximum flow rate not to exceed 2 /gallons per minute(2.5 gpm)
Faucets with maximum flow rate not to exceed 2 2/10 gallons per minute(2.2 gpm)
Ultra-low flush water closets(toilets)not to exceed 1 6/10 gallons per flush(1.6 gpf)
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 licensed plumber must install the water closets and submetering equipment.
Submetering equipment information: Norgas Metering Technologies Inc Versamag Poly
Manufacturer Model#
Licensed Plumber Certification
AUGPaul LeGault 19756
Print Name of Plumber License# Date
I certify that(check all that apply):
®I have installed the submetering equipment listed above in accordance with accepted plumbing standards.
❑I have installed one or more water closets not exceeding 1.6 gallons per flush.
® Determined that existing water closets do not exceed 1.6 gallons per flush.
❑ The plumbing permit issued by the city/town, if required, is attached.
❑Dwelling unit is connected directly to a meter installed by a water company and, in accordance with
M.G.L.c. 186, §22(p),does not require the installation of a submeter.
Signed under the pains and penalties of perjury, RO-Z
Signature of Licensed Plumber
Property Owner Certification
I certify that: (1)This dwelling unit is eligible for the imposition on the tenants of a charge for water and/or sewer usage
in accordance with the water submetering law(MGL c. 186, §22); (2)All showerheads, faucets, and water closets in this
dwelling unit are water conservation devices that meet the standards specified above; (3)The water submeter measuring
the use of water in the dwelling unit was installed by a licensed plumber and is in compliance with the standards
specified above, or the water meter measuring the use of water in this dwelling unit was installed by a"water company"
as defined in 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)That all information included on
this certification is true and accurate to the best of my knowledge.
Signed under the pains and penalties
of perjury,
,v
Print Name of Owner i nature of Owner
Date 171 k-
The property has been transferred to owner above and the unit Received
remains in compliance with the requirements of M.G.L. c. 186, §22 Date: by BOH:
*THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBMETERING
CITY OF SALEM
MDPH-CSP Submetering Form,Rev 11-4-16 BOARD OF HEALTH
m
MASSACHUSETTS 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:Minimum Standards of Fitness for Human Habitation
(State Sanitary Code Chapter II),the following dwelling unit is eligible for the imposition on the tenants of a charge for
water and/or sewer service.
PROPERTY INFORMATION
Address: Reliance Row Unit# 4 #Of units in bld . 11
City/Town: Salem MA Zip Code: 01970
EQUIPMENT INSTALLATION INFORMATION
105 CMR 410.000 requires the installation of water conservation devices prior to a dwelling unit becoming eligible for the
imposition on tenants of a charge for water and/or sewer. The devices must meet the following specifications:
Showerheads with maximum flow rate not to exceed 2 /'gallons per minute(2.5 gpm)
Faucets with maximum flow rate not to exceed 2 2/10 gallons per minute(2.2 gpm)
Ultra-low flush water closets(toilets)not to exceed 1 6/10 gallons per flush(1.6 gpf).
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 licensed plumber must install the water closets and submetering equipment.
Submetering equipment information: Norgas Metering Technologies Inc Versamag Poly
Manufacturer Model#
Licensed Plumber Certification
Paul LeGault 19756 + f
Print Name of Plumber License# Date
I certify that(check all that apply):
21 have installed the submetering equipment listed above in accordance with accepted plumbing standards.
❑ I have installed one or more water closets not exceeding 1.6 gallons per flush.
�I Determined that existing water closets do not exceed 1.6 gallons per flush.
❑ The plumbing permit issued by the city/town,if required, is attached.
❑ Dwelling unit is connected directly to a meter installed by a water company and, in accordance with
M.G.L . c. 186, §22(p),does not require the installation of a submeter.
Signed under the pains and penalties of perjury, Role z ..
Signature of Licensed Plumber
Property Owner Certification
I certify that:(1)This dwelling unit is eligible for the imposition on the tenants of a charge for water and/or sewer usage
in accordance with the water submetering law(MGL c. 186, §22); (2)All showerheads, faucets, and water closets in this
dwelling unit are water conservation devices that meet the standards specified above; (3)The water submeter measuring
the use of water in the dwelling unit was installed by a licensed plumber and is in compliance with the standards
specified above, or the water meter measuring the use of water in this dwelling unit was installed by a"water company"
as defined in 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)That all information included on
this certification is true and accurate to the best of my knowledge.
Signed un r the and penalties of perjury,
Print Name of Owner Si nature of Owner
Date
The property has been transferred to owner above and the unit Received
remains in compliance with the requirements of M.G.L.c. 186, §22 Date: b% BOH: SEP 18 2020
*THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBWEV ZFF SALEM
MDPH-CSP Submetering Form,Rev l 1-4-16
BOARD OF HEALTH
MASSACHUSETTS 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:Minimum Standards of Fitness for Human Habitation
(State Sanitary Code Chapter II),the following dwelling unit is eligible for the imposition on the tenants of a charge for
water and/or sewer service.
PROPERTY INFORMATION
Address: Reliance ROW Unit# 5 #Of units in bldg. 11
City/Town: Salem MA Zi Code: 01970
EQUIPMENT INSTALLATION INFORMATION
105 CMR 410.000 requires the installation of water conservation devices prior to a dwelling unit becoming eligible for the
imposition on tenants of a charge for water and/or sewer. The devices must meet the following specifications:
Showerheads with maximum flow rate not to exceed 2 Y�gallons per minute(2.5 gpm)
Faucets with maximum flow rate not to exceed 2 2/10 gallons per minute(2.2 gpm)
Ultra-low flush water closets(toilets)not to exceed 1 6/10 gallons per flush(1.6 gpf)
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 licensed plumber must install the water closets and submetering equipment.
Submetering equipment information: Norgas Metering Technologies Inc Versamag Poly
Manufacturer Model#
Licensed Plumber Certification
2021
Paul LeGault 19756 �� 1 o
Print Name of Plumber License# Date
I certify that(check all that apply):
®I have installed the submetering equipment listed above in accordance with accepted plumbing standards.
❑I have installed one or more water closets not exceeding 1.6 gallons per flush.
® Determined that existing water closets do not exceed 1.6 gallons per flush.
❑ The plumbing permit issued by the city/town, if required, is attached.
❑Dwelling unit is connected directly to a meter installed by a water company and, in accordance with
M.G.L. c. 186, § 22(p),does not require the installation of a submeter.
Signed under the pains and penalties of perjury,
Si,nature of Licensed Plumber
Property Owner Certification
I certify that:(1)This dwelling unit is eligible for the imposition on the tenants of a charge for water and/or sewer usage
in accordance with the water submetering law(MGL c. 186, §22); (2)All showerheads, faucets, and water closets in this
dwelling unit are water conservation devices that meet the standards specified above; (3)The water submeter measuring
the use of water in the dwelling unit was installed by a licensed plumber and is in compliance with the standards
specified above,or the water meter measuring the use of water in this dwelling unit was installed by a"water company"
as defined in 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)That all information included on
this certification is true and accurate to the best of my knowledge.
Signed and the ai and penalties of perjury,
(,Z4
Print Name of Owner Si nature of Owner D
Date
The property has been transferred to owner above and the unit Received
remains in compliance with the require ents of M.G.L. c. 186, §22 Date: b; BOH: SEP 18 2020
*THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUB�YERI SALEM
MDPH-CSP Submetering Form,Rev 11-4-16
BOARD OF HEALTH
MASSACHUSETTS 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:Minimum Standards of Fitness for Human Habitation
(State Sanitary Code Chapter II),the following dwelling unit is eligible for the imposition on the tenants of a charge for
water and/or sewer service.
PROPERTY INFORMATION
Address: Reliance Row Unit# 6 #Of units in bldg. 11
City/Town: Salem MA Zip Code: 01970
EQUIPMENT INSTALLATION INFORMATION
105 CMR 410.000 requires the installation of water conservation devices prior to a dwelling unit becoming eligible for the
imposition on tenants of a charge for water and/or sewer. The devices must meet the following specifications:
Showerheads with maximum flow rate not to exceed 2 i�gallons per minute(2.5 gpm)
Faucets with maximum flow rate not to exceed 2 2"0 gallons per minute(2.2 gpm)
Ultra-low flush water closets(toilets)not to exceed 1 6"0 gallons per flush(1.6 gpf)
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 licensed plumber must install the water closets and submetering equipment.
Submetering equipment information: Norgas Metering Technologies Inc Versamag Poly
Manufacturer Model#
Licensed Plumber Certification
Paul LeGault 19756 iA V6 ,10 i
Print Name of Plumber License# Date
I certify that(check all that apply):
®I have installed the submetering equipment listed above in accordance with accepted plumbing standards.
❑ I have installed one or more water closets not exceeding 1.6 gallons per flush.
® Determined that existing water closets do not exceed 1.6 gallons per flush.
❑ The plumbing permit issued by the city/town, if required, is attached.
❑ Dwelling unit is connected directly to a meter installed by a water company and,in accordance with
M.G.L . c. 186, §22(p), does not require the installation of a submeter.
Signed under the pains and penalties of perjury,
Siti�nature of Licensed Plumber
Property Owner Certification
I certify that:(1)This dwelling unit is eligible for the imposition on the tenants of a charge for water and/or sewer usage
in accordance with the water submetering law(MGL c. 186, §22); (2)All showerheads,faucets,and water closets in this
dwelling unit are water conservation devices that meet the standards specified above; (3)The water submeter measuring
the use of water in the dwelling unit was installed by a licensed plumber and is in compliance with the standards
specified above, or the water meter measuring the use of water in this dwelling unit was installed by a"water company"
as defined in 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)That all information included on
this certification is true and accurate to the best of my knowledge.
Signed under the pains and penalties of perjury,
C-5444 J�?01 C_ cl�
Print Name of Owner Si nature of Owner rg €D
Date
The property has been transferred to owner above and the unit Received
remains in compliance with the requirements of M.G.L. c. 186, §22 Date: b BOH: SEP 18 2020
*THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUB�YFIJGALEM
BOARD OF HEALTH
NIDPH-CSP Submetering Form,Rev 11-4-16
MASSACHUSETTS 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:Minimum Standards of Fitness for Human Habitation
(State Sanitary Code Chapter II),the following dwelling unit is eligible for the imposition on the tenants of a charge for
water and/or sewer service.
PROPERTY INFORMATION
Address: Reliance Row Unit# 7 #Of units in bldg. 11
City/Town: Salem MA Zip Code: 01970
EQUIPMENT INSTALLATION INFORMATION
105 CMR 410.000 requires the installation of water conservation devices prior to a dwelling unit becoming eligible for the
imposition on tenants of a charge for water and/or sewer. The devices must meet the following specifications:
Showerheads with maximum flow rate not to exceed 2 Y,gallons per minute(2.5 gpm)
Faucets with maximum flow rate not to exceed 2 2"0 gallons per minute(2.2 gpm)
Ultra-low flush water closets (toilets)not to exceed 1 6"0 gallons per flush(1.6 gpf)
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 licensed plumber must install the water closets and submetering equipment.
Submetering equipment information: Norgas Metering Technologies Inc Versamag Poly
Manufacturer Model #
Licensed Plumber Certification
Paul LeGault 19756
Print Name of Plumber License# Date
I certify that(check all that apply):
®I have installed the submetering equipment listed above in accordance with accepted plumbing standards.
❑I have installed one or more water closets not exceeding 1.6 gallons per flush.
® Determined that existing water closets do not exceed 1.6 gallons per flush.
❑ The plumbing permit issued by the city/town, if required, is attached.
❑Dwelling unit is connected directly to a meter installed by a water company and, in accordance with
M.G.L. c. 186, §22(p), does not require the installation of a submeter.
Signed under the pains and penalties of perjury, pi-e
Signature of Licensed Plumber
Property Owner Certification
I certify that: (1)This dwelling unit is eligible for the imposition on the tenants of a charge for water and/or sewer usage
in accordance with the water submetering law(MGL c. 186, §22); (2)All showerheads, faucets,and water closets in this
dwelling unit are water conservation devices that meet the standards specified above; (3)The water submeter measuring
the use of water in the dwelling unit was installed by a licensed plumber and is in compliance with the standards
specified above,or the water meter measuring the use of water in this dwelling unit was installed by a"water company"
as defined in M.G.L.c. 186, § 22; (4)The water meter or submeter measures the water usage exclusive to this unit;(5)I
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)That all information included on
this certification is true and accurate to the best of my knowledge.
Signed u der ie pains ,nd p :alties of perjury,
Print N me of Owner Signature of Owner p�
Date L
The property has been transferred to owner above and the unit Received
remains in compliance with the requirements of M.G.L. c. 186, §22 Date: bv BOH:
*THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBMETERING
CITY OF SALEM
MDPH-CSP Submetering Form,Rev 11-4-16 BOARD OF HEALTH
MASSACHUSETTS 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: Minimum Standards of Fitness for Human Habitation
(State Sanitary Code Chapter II),the following dwelling unit is eligible for the imposition on the tenants of a charge for
water and/or sewer service.
PROPERTY INFORMATION
Address: Reliance Row Unit# 8 #Of units in bldg. 11
City/Town: Salem MA Zip Code: 01970
INFORMATION
EQUIPMENT INSTALLATION INFOR
105 CMR 410.000 requires the installation of water conservation devices prior to a dwelling unit becoming eligible for the
imposition on tenants of a charge for water and/or sewer. The devices must meet the following specifications:
Showerheads with maximum flow rate not to exceed 2 !/�gallons per minute(2.5 gpm)
Faucets with maximum flow rate not to exceed 2 2/10 gallons per minute(2.2 gpm)
Ultra-low flush water closets toilets not to exceed 1 6/1°
(toilets) gallons per flush(1.6 gpf)
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 licensed plumber must install the water closets and submetering equipment.
Submetering equipment information: Norgas Metering Technologies Inc Versamag Poly
Manufacturer Model#
Licensed Plumber Certification Amu Paul LeGault 19756 '£
Print Name of Plumber License# Date
I certify that(check all that apply):
®I have installed the submetering equipment listed above in accordance with accepted plumbing standards.
❑ I have installed one or more water closets not exceeding 1.6 gallons per flush.
® Determined that existing water closets do not exceed 1.6 gallons per flush.
❑ The plumbing permit issued by the city/town, if required, is attached.
❑ Dwelling unit is connected directly to a meter installed by a water company and, in accordance with
M.G.L . c. 186, §22(p), does not require the installation of a submeter.
Signed under the pains and penalties of perjury, t r
Signature of Licensed Plumber
Property Owner Certification
I certify that: (1)This dwelling unit is eligible for the imposition on the tenants of a charge for water and/or sewer usage
in accordance with the water Submetering law(MGL c. 186, §22); (2)All showerheads,faucets,and water closets in this
dwelling unit are water conservation devices that meet the standards specified above; (3)The water submeter measuring
the use of water in the dwelling unit was installed by a licensed plumber and is in compliance with the standards
specified above, or the water meter measuring the use of water in this dwelling unit was installed by a"water company"
as defined in M.G.L. c. 186, § 22; (4)The water meter or submeter measures the water usage exclusive to this unit; (5)I
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)That all information included on
this certification is true and accurate to the best of my knowledge.
Signed Li e e p ' s nd penalties of perjury,
Prmt ame of Owner Signature of OwnerEl `
7Received
ate D
The property has been transferred to owner above and the unit
remains in compliance with the requirements of M.G.L.c. 186, 22 Date: y BOH:
*THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBMETERING
CITY OF SALEM
MDPH-CSP Submetering Form,Rev 11-4-16 BOARD OF HEALTH
MASSACHUSETTS 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: Minimum Standards of Fitness for Human Habitation
(State Sanitary Code Chapter II), the following dwelling unit is eligible for the imposition on the tenants of a charge for
water and/or sewer service.
PROPERTY INFORMATION
Address: Reliance Row Unit# 9 #Of units in bldg. 11
City/Town: Salem MA Zip Code: 01970
EQUIPMENT INSTALLATION INFORMATION
105 CMR 410.000 requires the installation of water conservation devices prior to a dwelling unit becoming eligible for the
imposition on tenants of a charge for water and/or sewer.The devices must meet the following specifications:
Showerheads with maximum flow rate not to exceed 2 1/1 gallons per minute (2.5 gpm)
Faucets with maximum flow rate not to exceed 2 2"0 gallons per minute(2.2 gpm)
Ultra-low flush water closets (toilets)not to exceed 1 6/10 gallons per flush(1.6 gpf)
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 licensed plumber must install the water closets and submetering equipment.
Submetering equipment information: Norgas Metering Technologies Inc Versamag Poly
Manufacturer Model#
Licensed Plumber Certification
Paul LeGault 19756 v .10
Print Name of Plumber License# Date
I certify that(check all that apply):
®I have installed the submetering equipment listed above in accordance with accepted plumbing standards.
❑ I have installed one or more water closets not exceeding 1.6 gallons per flush.
® Determined that existing water closets do not exceed 1.6 gallons per flush.
❑ The plumbing permit issued by the city/town, if required, is attached.
❑ Dwelling unit is connected directly to a meter installed by a water company and, in accordance with
M.G.L.c. 186, §22(p), does not require the installation of a submeter.
Signed under the pains and penalties of perjury, /Va-z
Signature of Licensed Plumber
Property Owner Certification
I certify that: (1)This dwelling unit is eligible for the imposition on the tenants of a charge for water and/or sewer usage
in accordance with the water submetering law(MGL c. 186, §22);(2)All showerheads, faucets,and water closets in this
dwelling unit are water conservation devices that meet the standards specified above; (3)The water submeter measuring
the use of water in the dwelling unit was installed by a licensed plumber and is in compliance with the standards
specified above,or the water meter measuring the use of water in this dwelling unit was installed by a"water company"
as defined in M.G.L.c. 186, § 22; (4)The water meter or submeter measures the water usage exclusive to this unit; (5)I
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 co of this certification form; (6)That all information included on
this certification is true and accurate to the best of my k owledge.
Signed, der t pain gad al ies of perjury,
A
— " �Ab&o
Print Name of Owne , i nature fff OwNw Date
Date D
The property has been transferred to owner above and the unit Received
remains in compliance with the requirements of M.G.L.c. 186, §22 Date: by BOH:
*THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUB E E G
CITY OF SALEM
MDPH-CSP Submetering Form,Rev 11-4-16 BOARD OF HEALTH
MASSACHUSETTS 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:Minimum Standards of Fitness for Human Habitation
(State Sanitary Code Chapter II),the following dwelling unit is eligible for the imposition on the tenants of a charge for
water and/or sewer service.
PROPERTY INFORMATION
Address: Reliance Row Unit# 10 #Of units in bldg. 11
City/Town: Salem MA Zip Code: 01970
EQUIPMENT INSTALLATION INFORMATION
105 CMR 410.000 requires the installation of water conservation devices prior to a dwelling unit becoming eligible for the
imposition on tenants of a charge for water and/or sewer. The devices must meet the following specifications:
Showerheads with maximum flow rate not to exceed 2 /'gallons per minute (2.5 gpm)
Faucets with maximum flow rate not to exceed 2 z"0 gallons per minute(2.2 gpm)
Ultra-low flush water closets(toilets)not to exceed 1 6/1
0 gallons per flush(1.6 gpf)
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 licensed plumber must install the water closets and submetering equipment.
Submetering equipment information: Norgas Metering Technologies Inc Versamag Poly
Manufacturer Model#
Licensed Plumber Certification BUG 10 2000
Paul LeGault 19756
Print Name of Plumber License# Date
I certify that(check all that apply):
®I have installed the submetering equipment listed above in accordance with accepted plumbing standards.
❑ I have installed one or more water closets not exceeding 1.6 gallons per flush.
®Determined that existing water closets do not exceed 1.6 gallons per flush.
❑ The plumbing permit issued by the city/town, if required, is attached.
❑ Dwelling unit is connected directly to a meter installed by a water company and, in accordance with
M.G.L. c. 186, §22(p),does not require the installation of a submeter.
Signed under the pains and penalties of perjury, /V�
Signature of Licensed Plumber
Property Owner Certification
I certify that: (1)This dwelling unit is eligible for the imposition on the tenants of a charge for water and/or sewer usage
in accordance with the water submetering law(MGL c. 186, §22);(2)All showerheads, faucets, and water closets in this
dwelling unit are water conservation devices that meet the standards specified above; (3)The water submeter measuring
the use of water in the dwelling unit was installed by a licensed plumber and is in compliance with the standards
specified above,or the water meter measuring the use of water in this dwelling unit was installed by a"water company"
as defined in 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)That all information included on
this certification is true and accurate to the best of my knowledge.
Signed and r the pains and pe lties of perjury,
AA IVIIA
rint Name of caner Oignatlure gofKn�er
Date
The property has been transferred to owner above and the unit Received
remains in compliance with the requirements of M.G.L.c. 186, §22 Date: by BOH:
*THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBMETERING
CITY OF SALEM
MDPH-CSP Submetering Form,Rev 11-4-16 BOARD OF HEALTH
MASSACHUSETTS 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: Minimum Standards of Fitness for Human Habitation
(State Sanitary Code Chapter II),the following dwelling unit is eligible for the imposition on the tenants of a charge for
water and/or sewer service.
PROPERTY INFORMATION
Address: Reliance Row Unit# 12 #Of units in bldg. 11
Ci /Town: Salem MA Zi Code: 01970
EQUIPMENT INSTALLATION INFORMATION
105 CMR 410.000 requires the installation of water conservation devices prior to a dwelling unit becoming eligible for the
imposition on tenants of a charge for water and/or sewer.The devices must meet the following specifications:
Showerheads with maximum flow rate not to exceed 2 A gallons per minute(2.5 gpm)
Faucets with maximum flow rate not to exceed 2 2"0 gallons per minute(2.2 gpm)
Ultra-low flush water closets toilets not to exceed 1 6i'o
(toilets) gallons per flush(1.6 gpf)
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 licensed plumber must install the water closets and submetering equipment.
Submetering equipment information: Norgas Metering Technologies Inc Versamag Poly
Manufacturer Model#
Licensed Plumber Certification it Lt i )A
Paul LeGault 19756 -2924
Print Name of Plumber License# Date
I certify that(check all that apply):
®I have installed the submetering equipment listed above in accordance with accepted plumbing standards.
❑ I have installed one or more water closets not exceeding 1.6 gallons per flush.
®Determined that existing water closets do not exceed 1.6 gallons per flush.
❑The plumbing permit issued by the city/town, if required, is attached.
❑Dwelling unit is connected directly to a meter installed by a water company and,in accordance with
M.G.L. c. 186, §22(p), does not require the installation of a submeter.
Signed under the pains and penalties of perjury,
Signature of Licensed Plumber
Property Owner Certification
I certify that: (1)This dwelling unit is eligible for the imposition on the tenants of a charge for water and/or sewer usage
in accordance with the water submetering law(MGL c. 186, §22);(2)All showerheads, faucets, and water closets in this
dwelling unit are water conservation devices that meet the standards specified above; (3)The water submeter measuring
the use of water in the dwelling unit was installed by a licensed plumber and is in compliance with the standards
specified above,or the water meter measuring the use of water in this dwelling unit was installed by a"water company"
as defined in M.G.L. c. 186, §22; (4)The water meter or submeter measures the water usage exclusive to this unit; (5)I
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)That all information included on
this certification is true and accurate to the best of my knowledge.
Signed under the pains and penalties of perjury,
—Vz V�n I�A
�/v
Print Name of Owner Signature of Owner t D
11 Date
The property has been transferred to owner above and the unit Received 5 EP 1 $ 2020 remains in compliance with the requirements of M.G.L. c. 186, 22 Date: b BOH:
*THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SU"TFMLEM
BOARD OF HEALTH
NMPH-CSP Submetering Form,Rev 11-4-16