117 Weatherly Drive water and sewer submetering certification forms MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH
SUBMETERING OF WATER AND SEWER CERTIFICATION FORM
*In accordance with M.G.L. c. 186, § 22 and 105 CMR 410.000:Minimum Standards of Fitness for Human Habitation
(State Sanitary Code Chapter II),the following dwelling unit is eligible for the imposition on the tenants of a charge for
water and/or sewer service.
PROPERTY INFORMATION
Address: 117 Weatherly Dr Unit# 101 #Of units in bldg. 6
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 2
/'0 gallons per minute(2.2 gpm)
Ultra-low flush water closets(toilets)not to exceed 1 6/10 gallons per flush(1.6 gpf)
The submetering equipment used to measure the quantity of water used for each dwelling unit and common area must
meet the standards of accuracy and testing of the American Water Works Association or similar accredited association.
A licensed plumber must install the water closets and submetering equipment.
Submetering equipment information: Norgas-MeteringTechnologies Inc Versamag Poly
Manufacturer Model#
Licensed Plumber Certification
Paul LeGault 19756
Print Name of Plumber License# Date
I certify that(check all that apply):
®I have installed the submetering equipment listed above in accordance with accepted plumbing standards.
❑ I have installed one or more water closets not exceeding 1.6 gallons per flush.
®Determined that existing water closets do not exceed 1.6 gallons per flush.
❑The plumbing permit issued by the city/town, if required, is attached.
❑Dwelling unit is connected directly to a meter installed by a water company and, in accordance with
M.G.L .c. 186, § 22(p), does not require the installation of a submeter.
Signed under the pains and penalties of perjury,
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 enalties of perjury, J
Y
rint 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 require nents of M.G.L. c. 186, §22 Date: b • BOH: SEP 1 20d
*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: 117 Weatherly Dr Unit# 102 #Of units in bid . 6
Citv/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"0 gallons per flush(1.6 gpf)
The submetering equipment used to measure the quantity of water used for each dwelling unit and common area must
meet the standards of accuracy and testing of the American Water Works Association or similar accredited association.
A licensed plumber must install the water closets and submetering equipment.
Submetering equipment information: Norgas Metering Technologies Inc Versamag Poly
Manufacturer Model#
Licensed Plumber Certification
Paul LeGault 19756 � �
Print Name of Plumber License# Date
I certify that(check all that apply):
®I have installed the submetering equipment listed above in accordance with accepted plumbing standards.
❑I have installed one or more water closets not exceeding 1.6 gallons per flush.
® Determined that existing water closets do not exceed 1.6 gallons per flush.
❑The plumbing permit issued by the city/town, if required, is attached.
❑Dwelling unit is connected directly to a meter installed by a water company and, in accordance with
M.G.L. c. 186, § 22(p),does not require the installation of a submeter.
Signed under the pains and penalties of perjury, lva—e
Signature of Licensed Plumber
Property Owner Certification
I certify that: (1)This dwelling unit is eligible for the imposition on the tenants of a charge for water and/or sewer usage
in accordance with the water submetering law(MGL c. 186, §22);(2)All showerheads, faucets, and water closets in this
dwelling unit are water conservation devices that meet the standards specified above; (3)The water submeter measuring
the use of water in the dwelling unit was installed by a licensed plumber and is in compliance with the standards
specified above,or the water meter measuring the use of water in this dwelling unit was installed by a"water company"
as defined in M.G.L.c. 186, § 22; (4)The water meter or submeter measures the water usage exclusive to this unit; (5)I
will provide to the tenants of this dwelling unit,prior to occupancy,a written rental agreement that clearly provides for the
separate charging of water and/or sewer service,and a copy of this certification form; (6)That all information included on
this certification is true and accurate to the best of my knowledge.
Signed under the pains and penalties of perjury,
Prmt Name of Owner '-`Signature of Owner e
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, c22 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: 117 Weatherly Dr Unit# 201 #Of units in bldg. 6
City/Town: Salem MA Zip Code: 01970
EQUIPMENT INSTALLATION INFORMATION
105 CMR 410.000 requires the installation of water conservation devices prior to a dwelling unit becoming eligible for the
imposition on tenants of a charge for water and/or sewer. The devices must meet the following specifications:
Showerheads with maximum flow rate not to exceed 2 !/�gallons per minute(2.5 gpm)
Faucets with maximum flow rate not to exceed 2 2/10 gallons per minute(2.2 gpm)
Ultra-low flush water closets(toilets)not to exceed 1 6/10 gallons per flush(1.6 gpf)
The submetering equipment used to measure the quantity of water used for each dwelling unit and common area must
meet the standards of accuracy and testing of the American Water Works Association or similar accredited association.
A licensed plumber must install the water closets and submetering equipment.
Submetering equipment information: Norgas Metering Technologies Inc Versamag Poly
Manufacturer Model#
Licensed Plumber Certification AUG
Vklry ,
Paul LeGault 19756 W1�
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)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.
Signec order the pai and penalties of perjury,
� v
'rint Name of Owner Si <<ature of Owner Date
Date ECEIVE
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 SUB E I
CITY
MDPH-CSP Submetering Form,Rev 11-4-16 B O HEALTH 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: 117 Weatherly Dr Unit# 202 #Of units in bldg. 6
Cite/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 21 gallons per minute(2.2 gpm)
Ultra-low flush water closets(toilets)not to exceed 1 6/10 gallons per flush(1.6 gpf)
The submetering equipment used to measure the quantity of water used for each dwelling unit and common area must
meet the standards of accuracy and testing of the American Water Works Association or similar accredited association.
A licensed plumber must install the water closets and submetering equipment.
Submetering equipment information: Norgas Metering Technologies Inc Versamag Poly
Manufacturer Model #
Licensed Plumber Certification
Paul LeGault 19756 F�tG �Q �
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, 1V�z
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, A tak
f✓
&PrintName of Owner Signature of Owner Da
Date t D
The property has been transferred to owner above and the unit Received
remains in compliance with the re uirements 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: 117 Weatherly Dr Unit# 301 #Of units in bldg. 6
Citv/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 �S 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(toilets) gallons per flush(1.6 gpf)
The submetering equipment used to measure the quantity of water used for each dwelling unit and common area must
meet the standards of accuracy and testing of the American Water Works Association or similar accredited association.
A licensed plumber must install the water closets and submetering equipment.
Submetering equipment information: Norgas Metering Technologies Inc Versamag Poly
Manufacturer Model#
Licensed Plumber Certification I AUG
® 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. �7
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 nd penalties of perjury, b�
k,-- pAkd �
Print Name of Owner Signature of Owner 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: SEP 18 202
*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: 117 Weatherly Dr Unit# 302 #Of units in bld . 6
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"0 gallons per flush(1.6 gpf)
The submetering equipment used to measure the quantity of water used for each dwelling unit and common area must
meet the standards of accuracy and testing of the American Water Works Association or similar accredited association.
A licensed plumber must install the water closets and submetering equipment.
Submetering equipment information: Norgas Metering Technologies Inc Versamag Poly
Manufacturer Model#
Licensed Plumber Certification
Paul LeGault 19756 + �
Print Name of Plumber License# Date
I certify that(check all that apply):
®I have installed the submetering equipment listed above in accordance with accepted plumbing standards.
❑ I have installed one or more water closets not exceeding 1.6 gallons per flush.
® Determined that existing water closets do not exceed 1.6 gallons per flush.
❑ The plumbing permit issued by the city/town,if required, is attached.
❑Dwelling unit is connected directly to a meter installed by a water company and, in accordance with
M.G.L.c. 186, §22(p), does not require the installation of a submeter.
Signed under the pains and penalties of perjury, ��"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,
—�A�Wdxk Al PA
Print Name of Owner Signature of Owner Date
Date L El
D
The property has been transferred to owner above and the unit Received
remains in compliance with the requirements of M.G.L. c. 186, 22 Date: by BOH:
*THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUB E
CITY OF SALEM
MDPH-CSP Submetering Form,Rev 11-4-16 BOARD OF HEALTH