190 Bridge St. water and sewer submetering certification forms Units 2101-2415 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: 190 Bridge St. Unit# 2101 #Of units in bldg. 236
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.
Flexible Axis Meter
Submetering equipment information: Master Meter Inc FAM
Manufacturer Model#
Licensed Plumber Certification
Paul LeGault 19756 AUG ( 3
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 unde the pains and penalties of perjury,
lD
Print Name of Owner Si nature of Owner Date
El da—WeRL
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 tEftftj
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: 190 Bridge St. Unit# 2102 #Of units in bldg. 236
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 6110 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.
Flexible Axis Meter
Submetering equipment information: Master Meter Inc FAM
Manufacturer Model#
Licensed Plumber Certification AUG■ 10
2020
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, lv«"e ;iF 4
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)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 and the pains and penalties of perjury,
q/� zd
Print Name of Owner "Signature of Owner Date
Date RECEI
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 SU T R
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: 190 Bridge St. Unit# 2103 #Of units in bld!,,. 236
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.
Flexible Axis Meter
Submetering equipment information: Master Meter Inc FAM
Manufacturer Model#
Licensed Plumber Certification
Paul LeGault 19756 MUG ..,
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, /Vi-z 1z
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 under the pains and penalties of perjury, A"
VWILM v
Print Name of Owner Si nature of Owner Date
El Date 1C 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 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: 190 Bridge St. Unit# 2104 #Of units in bldg. 236
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 ''/'gallons per minute(2.5 gpm)
Faucets with maximum flow rate not to exceed 2 2110 gallons per minute(2.2 gpm)
Ultra-low flush water closets(toilets)not to exceed 1 6110 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.
Flexible Axis Meter
Submetering equipment information: Master Meter Inc FAM
Manufacturer Model#
Licensed Plumber Certification AUG(f,1 UG 10
2020
Paul LeGault 19756 LIJ
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 ;iF ku
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, Q
G
Print Name of Owner Signature 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: by BOH:qFp2OZO
*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: 190 Bridge St. Unit# 2105 #Of units in bldg. 236
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 '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.
Flexible Axis Meter
Submetering equipment information: Master Meter Inc FAM
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, 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)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 un er the ains and penalties of perjury,
Print Name of Owner Signature of Owner
Date R 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
NIDPH-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: 190 Bridge St. Unit# 2106 #Of units in bldg. 236
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 '/'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.
Flexible Axis Meter
Submetering equipment information: Master Meter Inc FAM
Manufacturer Model#
Licensed Plumber Certification AW is LUmj
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, ;9-z 1
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 knowle e.
Signed and r the pains and penalties of perjury,
Print Name of Owner Si nature of Owner
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 Box: SEP 18 2020
*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: 190 Bridge St. Unit# 2109 #Of units in bld 236
Cit /Town: Salem MA Zip Code: 01970
EQUIPMENT INSTALLATION INFORMATION
105 CMR 41.0.000 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.
Flexible Axis Meter
Submetering equipment information: Master Meter Inc FAM
Manufacturer Model#
Licensed Plumber Certification
Paul LeGault 19756
Print Name of Plumber License# Date
I certify that(check all that apply):
01 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, l `eSignature 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 unde the pains and penalties of perjury,
. Am� 47111Z6
Print Name of Owner Signature of Owner 47
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: H P 82020
*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: 190 Bridge St. Unit# 2110 #Of units in bldg. 236
City/To n: 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.
Flexible Axis Meter
Submetering equipment information: Master Meter Inc FAM
Manufacturer Model#
Licensed Plumber Certification It
2020
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, ;P4-z le
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 a pains and penalties of perjury,
Print Name of Owner V11tignature of Owner t
Date H E
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: �Fp 207
*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: 190 Bridge St. Unit# 2111 #Of units in bldg. 236
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/'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.
Flexible Axis Meter
Submetering equipment information: Master Meter Inc FAM
Manufacturer Model#
Licensed Plumber Certification OUG 10 2020
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, IV�`"z 1z k®�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,
�z /�Z�,4. _A�1 � ( 47f/`� '
Print Name of Owner Signature of Owner
El 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: 18 2020
*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: 190 Bridge St. Unit# 2112 #Of units in bldg. 236
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.
Flexible Axis Meter
Submetering equipment information: Master Meter Inc FAM
Manufacturer Model#
Licensed Plumber Certification
Paul LeGault 19756 ® ?O��
Print Name of Plumber License# Date
I certify that(check all that apply):
91 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, IViwz z au�
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 know edge.
Signed under the pains and penalties of perjury,
Print Name of Owner Signature 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: 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: 190 Bridge St. Unit# 2113 #Of units in bldg. 236
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 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.
Flexible Axis Meter
Submetering equipment information: Master Meter Inc FAM
Manufacturer Model#
Licensed Plumber Certification u
Paul LeGault 19756 �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,
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 un r the pains and enalties of perjury,
Print Name of Owner Signature of Owner Date
Date RECEIVED
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 T
N1DPH-CSP Submetering Form,Rev 11-4-16 BOA�O MFSHEALTH
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: 190 Bridge St. Unit# 2114 #Of units in bldg. 236
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 '/z 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.
Flexible Axis Meter
Submetering equipment information: Master Meter Inc FAM
Manufacturer Model#
Licensed Plumber Certification
Paul LeGault 19756 IA ® lax
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, �/ ®'��►J��`'-"`
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 pains and penalties of perjury,
Print Name of Owner Signature of Owner
Date � L 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 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: 190 Bridge St. Unit# 2115 #Of units in bldg. 236
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 ii 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.
Flexible Axis Meter
Submetering equipment information: Master Meter Inc FAM
Manufacturer Model#
Licensed Plumber Certification
Paul LeGault 19756 'AUG
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. O,j�
Signed under the pains and penalties of perjury, /I�{� e k
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 er the ains and penalties of perjury,
zo
Print Name of Owner ."Ianature of Owner Date
-4 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: o
*THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBMdt'RING
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: 190 Bridge St. Unit# 2201 #Of units in bldg. 236
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 !/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.
Flexible Axis Meter
Submetering equipment information: Master Meter Ine FAM
Manufacturer Model#
Licensed Plumber Certification ® 2020
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.
ri-z
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)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 er the pains and penalties of perjury,
Print Name of Owner Signature of Owner D
Date h
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: 190 Bridge St. Unit# 2202 #Of units in bldg. 236
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.
Flexible Axis Meter
Submetering equipment information: Master Meter Inc FAM
Manufacturer Model#
Licensed Plumber Certification WA 10 2020
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, de
�/
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 un er the pains and penalties of perjury,
r - &k M�_——
Print Name of Owner i nature of Owner Date
Date ®ECEiv
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: Avon
*THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBNktft
MDPH-CSP Submetering Form,Rev 11-4-16 CITY OF SALEM
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: 190 Bridge St. Unit# 2203 #Of units in bldg. 236
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 2110 gallons per minute(2.2 gpm)
Ultra-low flush water closets(toilets)not to exceed 1 610 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.
Flexible Axis Meter
Submetering equipment information: Master Meter Inc FAM
Manufacturer Model#
Licensed Plumber Certification 1�_■ I® 2020
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, /Vz 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,
Print Name of Owner ianature of Owner (� i late
Date
ED
The property has been transferred to owner above and the unit Received`EC E I V
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 SUBW9f AWL'
MDPH-CSP Submetering Form,Rev 11-4-16 CITY OF SALEM
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: 190 Bridge St. Unit# 2204 #Of units in bldg. 236
Ci /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.
Flexible Axis Meter
Submetering equipment information: Master Meter Inc FAM
Manufacturer Model#
Licensed Plumber Certification
Paul LeGault 19756 RUG 10 2020
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,
, jz_"44��
Print Name of Owner Signature of Owner RECEIVE
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: S E P 182020
*THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SU8NIMPTA-EM
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 I1),the following dwelling unit is eligible for the imposition on the tenants of a charge for
water and/or sewer service.
PROPERTY INFORMATION
Address: 190 Bridge St. Unit# 2205 #Of units in bldg. 236
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 V2 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.
Flexible Axis Meter
Submetering equipment information: Master Meter Inc FAM
Manufacturer Model#
Licensed Plumber Certification
Paul LeGault 19756 Wo
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.
® 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)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,
P,�
.Print Name o Owner Signature of Owner
El Date C-'U 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: b BOH: O2O
*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 lI),the following dwelling unit is eligible for the imposition on the tenants of a charge for
water and/or sewer service.
PROPERTY INFORMATION
Address: 190 Bridge St. Unit# 2206 #Of units in bldg. 236
Cit /Tow_ n: 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.
Flexible Axis Meter
Submetering equipment information: Master Meter Inc FAM
Manufacturer Model#
Licensed Plumber Certification
Paul LeGault 19756 ® LU4V
Print Name of Plumber License# Date
I certify that(check all that apply):
01 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, tvolz 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 under the pains and penalties of perjury,
Print Name of Owner Si nature of_Owner r
Date rl iZ
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:SEP 18 2020
*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: 190 Bridge St. Unit# 2207 # Of units in bldg. 236
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 i2 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.
Flexible Axis Meter
Submetering equipment information: Master Meter Inc FAM
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, 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)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 er the pains and penalties of perjury,
# Awl
/-
Print Name of Owner Signature of Owner D t
EI Date V 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 SUB METERING
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: 190 Bridge St. Unit# 2209 #Of units in bldg. 236
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 iz 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.
Flexible Axis Meter
Submetering equipment information: Master Meter Inc FAM
Manufacturer Model#
Licensed Plumber Certification -ADS
10 2020
Paul LeGault 19756
Print Name of Plumber License# Date
I certify that(check all that apply):
®1 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, )90-z lie
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 and the pains and penalties of perjury,
Print Name of Owner Signature of Owner Date
� Date f^i�CCl
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
CITY OF NMPH-CSP Submetering Form,Rev 11-4-16 BOAR 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: 190 Bridge St. Unit# 2210 #Of units in bldg. 236
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/L0 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.
Flexible Axis Meter
Submetering equipment information: Master Meter Inc FAM
Manufacturer 4 Model #
Licensed Plumber Certification lb� ® 2020
Paul LeGault 19756 6�
Print Name of Plumber License# Date
I certify that(check all that apply):
71 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. �j
Signed under the pains and penalties of perjury, /ilz
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 and°r the pains and penalties of perjury,
Print Name of Owner Si nature of Owner Dat 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: by BOH:
*THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBM TERING
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: 190 Bridge St. Unit# 2211 #Of units in bldg. 236
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.
Flexible Axis Meter
Submetering equipment information: Master Meter Inc FAM
Manufacturer Model#
Licensed Plumber Certification y� 12020
Paul LeGault 19756 �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.
�V,a.0
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,
fv - (? !
Print Name of Owner nature of Owner r7
El Date I IL- `—
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: S EP 18 2020
*THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBMET E
CITY
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: 190 Bridge St. Unit# 2212 #Of units in bldg. 236
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 vz 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.
Flexible Axis Meter
Submetering equipment information: Master Meter Inc FAM
Manufacturer Model#
Licensed Plumber Certification 9 2020
Paul LeGault 19756 vV 1!
Print Name of Plumber License# Date
I certify that(check all that apply):
0 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, 6
-�
Print Name of Owner Sip ature of Owner Date
El 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 SUB E ING
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: 190 Bridge St. Unit# 2213 #Of units in bldg. 236
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'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.
Flexible Axis Meter
Submetering equipment information: Master Meter Inc FAM
Manufacturer Model#
Licensed Plumber Certification � 2020
Paul LeGault 19756 �j('
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.
® 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)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,
Print Name of Owner Signature of Owner ,r—
Date t LZ.
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: SE P 18 2020
*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: 190 Bridge St. Unit# 2214 #Of units in bld . 236
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 v'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.
Flexible Axis Meter
Submetering equipment information: Master Meter Inc FAM
Manufacturer Model#
Licensed Plumber Certification
Paul LeGault 19756 '�UG ZOZQ
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 thepains and penalties of perjury,
///)
Print Name of Owner S4na e of Owner Date
13 Date MEGLI
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 SU NW
-
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: 190 Bridge St. Unit# 2215 #Of units in bldQ. 236
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.
Flexible Axis Meter
Submetering equipment information: Master Meter Ine FAM
Manufacturer Model#
Licensed Plumber Certification 0 202
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)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,
p
zel�� — A o Vi Z
Print Name of Owner Signature of Owner r-
El 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: SEP 18 2020
*THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUT,4E,T�FING
SALEM
MDPH-CSP Submetering Form,Rev 11-4-16 BOAM 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: 190 Bridge St. Unit# 2301 #Of units in bldv. 236
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.
Flexible Axis Meter
Submetering equipment information: Master Meter Inc FAM
Manufacturer Model#
Licensed Plumber Certification
Paul LeGault 19756 Nuu ,10 202b
Print Name of Plumber License# Date
I certify that(check all that apply):
®1 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, 0
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 tilider the ains and penalties of perjury,
Print Name of Owner Signature of Own RB ► —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 182020
*THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBMET OFG
CITYSALEM
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: 190 Bridge St. Unit# 2302 #Of units in bld . 236
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/'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.
Flexible Axis Meter
Submetering equipment information: Master Meter Inc FAM
Manufacturer Model#
Licensed Plumber Certification .A"I" ® LoLO
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, 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)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,
Print Rame of Owner —Signature of Owner
Date t:
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
NIDPH-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: 190 Bridge St. Unit# 2303 #Of units in bld:_. 236
City/Town: Salem MA Zi2 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.
Flexible Axis Meter
Submetering equipment information: Master Meter Inc FAM
Manufacturer Model#
Licensed Plumber Certification "I
Paul LeGault 19756 �`l� � A
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, J
• ( A /l
Print Name of Owner Signature o er11 Da
Date KtutIVED
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: 190 Bridge St. Unit# 2304 #Of units in bldg. 236
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 '/'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.
Flexible Axis Meter
Submetering equipment information: Master Meter Inc FAM
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. �j�
Signed under the pains and penalties of perjury, / a�
ie
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,
Print Name of Owner Signature of Owner wtpas
Date R1=
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
1
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 1I),the following dwelling unit is eligible for the imposition on the tenants of a charge for
water and/or sewer service.
PROPERTY INFORMATION
Address: 190 Bridge St. Unit# 2305 #Of units in bldg. 236
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 Y2 gallons per minute(2.5 gpm)
Faucets with maximum flow rate not to exceed 2 2110 gallons per minute(2.2 gpm)
Ultra-low flush water closets(toilets)not to exceed 1 6110 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.
Flexible Axis Meter
Submetering equipment information: Master Meter Inc FAM
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.
Signed un er the ains and penalties of perjury,Q�XA=77= V
15
/_Zc�
Print Name of Owner _ Signature of Owner
Fl 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: SEP 18 2020
*THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUCME EKINGG
F SALEM
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: 190 Bridge St. Unit# 2306 #Of units in bldg. 236
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.
Flexible Axis Meter
Submetering equipment information: Master Meter Inc FAM
Manufacturer Model#
Licensed Plumber Certification PUG G f fin`l�, 2020
Paul LeGault 19756 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, tvoz R Az �—r
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-r the pains and penalties of perjury,
# - A&d�- - 2 X �XJ
Print Name of Owner of Owner r—
Date
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: b BOH: SEP 18 22G020
*THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBCM Y 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: 190 Bridge St. Unit# 2307 #Of units in bldg. 236
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 2110 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.
Flexible Axis Meter
Submetering equipment information: Master Meter inc FAM
Manufacturer Model #
Licensed Plumber Certification
Paul LeGault 19756 ® 2020
Print Name of Plumber License# Date
I certify that(check all that apply):
®1 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, Rol /
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 unde the pains and penalties of perjury,194 Q�
�// 7
- �- dw�ql—A�—9�—
Print Name of Owner Signature of Owner
Date 1L f 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: f 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: 190 Bridge St. Unit# 2309 #Of units in bld,-. 236
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 2/10 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.
Flexible Axis Meter
Submetering equipment information: Master Meter Inc FAM
Manufacturer Model#
Licensed Plumber Certification
Paul LeGault 19756 +�UG 10 2� �
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 der the ains and penalties of perjury, l
Print Name of Owner ignature of Owner
Date
The property has been transferred to owner above and the unit Received
remains in com liance with the requirements of M.G.L. c. 186, §22 Date: by BOH: S F P 18 2020
*THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBMETERING
CITY OF SALEM
NIDPH-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: 190 Bridge St. Unit# 2310 #Of units in bldg. 236
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"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.
Flexible Axis Meter
Submetering equipment information: Master Meter Inc FAM
Manufacturer Model#
Licensed Plumber Certifications
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.
Signed under the pains And penalties of perjury,
Print Name of Owner Signature of Owner
Date 1—
❑ 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 Box: SEP 1 8 2020
*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: 190 Bridge St. Unit# 2311 #Of units in bldg. 236
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 v�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.
Flexible Axis Meter
Submetering equipment information: Master Meter Inc FAM
Manufacturer Model#
Licensed Plumber Certification ILAUG 1® 2020
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.
Signed under the pains and penalties of perjury,
J/Zo
z1d. Id IF12�� AAkZ7�7-,-"
Print Name of Owner Si nature of Owner
Date M C
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.
*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: 190 Bridge St. Unit# 2312 #Of units in bldg. 236
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 6110 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.
Flexible Axis Meter
Submetering equipment information: Master Meter Inc FAM
Manufacturer Model#
Licensed Plumber Certification 1AUG ® 2020
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. �V e
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, /
A/Zynr,&__A�
Print Name of Owner Signature of Owner
Date I IL—WL-1
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:S E P 18 2020
*THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBMETERING
CITY OF SALEM
BOARD OF HEALTH
MDPH-CSP Submetering Form,Rev l I-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: 190 Bridge St. Unit# 2313 #Of units in bldg. 236
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.
Flexible Axis Meter
Submetering equipment information: Master Meter Inc FAM
Manufacturer Model#
Licensed Plumber Certification ® g���
Paul LeGault 19756 C
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 unde the pains and penalties of perjury,
- �3�
Print Name of Owner SYgnature 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: by BOH: S Ep 18 2020
*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 I1),the following dwelling unit is eligible for the imposition on the tenants of a charge for
water and/or sewer service.
PROPERTY INFORMATION
Address: 190 Bridge St. Unit# 2314 #Of units in bl&. 236
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 '/'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.
Flexible Axis Meter
Submetering equipment information: Master Meter Inc FAM
Manufacturer Model#
Licensed Plumber Certification 'APJG D 2020
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.
Signed under the pains and penalties of perjury,
U4A
V40-
i nt Name o wner _ Si-nature of Owner Date
Jy Date p
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 SUBM&EMIG
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: 190 Bridge St. Unit# 2315 #Of units in bldg. 236
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 Vz 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.
Flexible Axis Meter
Submetering equipment information: Master Meter Inc FAM
Manufacturer Model#
Licensed Plumber Certification
Paul LeGault 19756 �� ® �"Q�
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 un r the ains and penalties of perjury, ao U�—�
Print Name of Owner Signature of OwnerEl t
Dateh=UC:IVMJ
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: 8 Mg
*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: 190 Bridge St. Unit# 2401 #Of units in bldg. 236
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
1
L0 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.
Flexible Axis Meter
Submetering equipment information: Master Meter Inc FAM
Manufacturer Model#
Licensed Plumber Certification M ® 202
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. J
Signed under the pains and penalties of perjury, ,/C
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 unde the pains and penalties of perjury,
9 6*" ?/) )/_Z�
Print Name of Owner _ _. iLttature of Owner
Date h i=
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: 0
*THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBMETERING
CITY OF SALEM
NWPH-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: 190 Bridge St. Unit# 2402 #Of units in bldg. 236
Cit /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 iz 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.
Flexible Axis Meter
Submetering equipment information: Master Meter Inc FAM
Manufacturer Model#
Licensed Plumber Certification ING
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, �I.e
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)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, l
Print Name of Owner Signature of Owner Date
Date RL--UEIV
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 I
CITY OF SALEM
1VIDPH-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: 190 Bridge St. Unit# 2403 #Of units in bldg. 236
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.
Flexible Axis Meter
Submetering equipment information: Master Meter Inc FAM
Manufacturer Model #
Licensed Plumber Certification
Paul LeGault 19756 r�� 1 2020
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, MK-
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 er the ains and penalties of perjury,
Print Name of Owner lignYure 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: 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: 190 Bridge St. Unit# 2404 #Of units in bldg. 236
—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.
Flexible Axis Meter
Submetering equipment information: Master Meter Inc FAM
Manufacturer Model #
Licensed Plumber Certification sm 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,
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 der the pans and penalties of perjury,
. &�� �-
Print Name of Owner —inatuYe of Owner
Date rl 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:q F P I A 2070
*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: 190 Bridge St. Unit# 2405 #Of units in bldg. 236
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.
Flexible Axis Meter
Submetering equipment information: Master Meter Inc FAM
Manufacturer Model#
Licensed Plumber Certification
Paul LeGault 19756 UG
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. -�}}
//wc'
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 and the pains and penalties of perjury,
0
U6 7/,zz,
Print Name of Owner Signature of Owner Date
Dat
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 BO
*THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING S MET RING
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: 190 Bridge St. Unit# 2406 #Of units in bldg. 236
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.
Flexible Axis Meter
Submetering equipment information: Master Meter Inc FAM
Manufacturer Model#Licensed Plumber Certification P AUG 10 2020
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� )F ku
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 ie pains and penalties of perjury,
Print Name of Owner Si na ure Owner
Date nL— v
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: 18 2020
*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: 190 Bridge St. Unit# 2407 #Of units in bld:,. 236
—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 2/0 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.
Flexible Axis Meter
Submetering equipment information: Master Meter Inc FAM
Manufacturer Model #
Licensed Plumber Certification 'AUG 10 2020
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. �� 0A ow— �
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)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 he pains and penalties of perjury,
Print Name of Owner Signature of Owner �
Date LE
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: S EP 18 202
*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 1I),the following dwelling unit is eligible for the imposition on the tenants of a charge for
water and/or sewer service.
PROPERTY INFORMATION
Address: 190 Bridge St. Unit# 2409 #Of units in bldo, 236
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 iz 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.
Flexible Axis Meter
Submetering equipment information: Master Meter Inc FAM
Manufacturer Model#
Licensed Plumber Certification
Paul LeGault 19756 'AUG ® �020
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. �� z Avjrc �,
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 un wr the pains and penalties of perjury,
Print Name of Owner Signature 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: by BOH: SEP 18 2020
*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: 190 Bridge St. Unit# 2410 #Of units in bldg. 236
Ciiy/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.
Flexible Axis Meter
Submetering equipment information: Master Meter Inc FAM
Manufacturer Model #
Licensed Plumber Certification
PAUG
Paul LeGault 19756 ® 2020
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,
10� 'Vxy=4� �A RMA��
Print Name of Owner V ' Signature of Owner
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,L22 Date: by BOH: S F P 1 9 2020
*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: 190 Bridge St. Unit# 2411 #Of units in bldg. 236
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 !/2 gallons per minute(2.5 gpm)
Faucets with maximum flow rate not to exceed 2 z110 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.
Flexible Axis Meter
Submetering equipment information: Master Meter Inc FAM
Manufacturer Model #
Licensed Plumber Certification } ® 2020
Paul LeGault 19756 t
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, 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 under the pains and penalties of perjury,
�1
Print Name of Owner VSignature of Owner Date
El Date RE-Ut IV It
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 SU E ING
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: 190 Bridge St. Unit# 2412 #Of units in bldg. 236
City/Town: Salem MA Zi2 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"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.
Flexible Axis Meter
Submetering equipment information: Master Meter Inc FAM
Manufacturer , Model#
Licensed Plumber Certification AUG ® 2020
Paul LeGault 19756
Print Name of Plumber License# Date
I certify that(check all that apply):
0 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, /Vemz
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 the pains and penalties of perjury,
4vho�<� - T// pev
Print Name of Owner 7Z nature of Ow er
Date n�—
❑ 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 Box: SEP 18 2020
*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 130AHD 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: 190 Bridge St. Unit# 2413 #Of units in bldg. 236
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.
Flexible Axis Meter
Submetering equipment information: Master Meter Inc FAM
Manufacturer Model#
Licensed Plumber Certification M�+� ® ����
Paul LeGault 19756 E UV
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, ��"L •
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 and r the pains and penalties of perjury,
__ _
Print Name of Owner _ f V 9i n ture of Owner D
Date
F-1 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: SEP 18 202
*THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUB�fTf RgALEM
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 1I),the following dwelling unit is eligible for the imposition on the tenants of a charge for
water and/or sewer service.
PROPERTY INFORMATION
Address: 190 Bridge St. Unit# 2414 #Of units in bld . 236
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 '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.
Flexible Axis Meter
Submetering equipment information: Master Meter Inc FAM
Manufacturer Model#
Licensed Plumber Certification AUG
10
2020
Paul LeGault 19756
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.
® 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, 1'M'"c 1z kz�_.__.__
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 der th ains and penalties of perjury,
Print Name of Owner I-,, ,,nature of Owner P4
,r J
Date
EI 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: SEP 18 2020
*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: 190 Bridge St. Unit# 2415 #Of units in bldg. 236
City/Town: Salem MA Zi p 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 2J10 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.
Flexible Axis Meter
Submetering equipment information: Master Meter Inc FAM
Manufacturer Model#
Licensed Plumber Certification Mo
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.
Signed un r the pains and penalties of perjury,
• 1 '/�
Print Name of Owner Signature of Owner e f 7 IV
Date
The property has been transferred to owner above and the unit Received S E P 18 202
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 SUB'�,W�J 13ALEM
BOARD OF HEALTH
NIDPH-CSP Submetering Form,Rev 11-4-16