1 Courageous Court water and sewer submetering certification forms Units 101-206 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 imbosition on the tenants of a charge for
water and/or sewer service.
PROPERTY INFORMATION
Address: 1 Courageous Ct. Unit# 101 4 Of units in bldg. 61
City/Town: Salem MA Zip Code: 01970
EQUIPMENT INSTALLATION INFORMATION
105 CMR 410.000 requires the installation of water conservation devices prior to a dwelling unit becoming eligible for the
imposition on tenants of a charge for water and/or sewer. The devices must meet the following specifications:
Showerheads with maximum flow rate not to exceed 2 Y'gallons per minute (2.5 gpm)
Faucets with maximum flow rate not to exceed 2 2"0 gallons per minute(2.2 gpm)
Ultra-low flush water closets(toilets)not to exceed 1 6"0 gallons per flush(1.6 gpf)
The submetering equipment used to measure the quantity of water used for each dwelling unit and common area must
meet the standards of accuracy and testing of the American Water Works Association or similar accredited association.
A licensed plumber must install the water closets and submetering equipment.
Submetering equipment information: Norgas Metering Technologies Inc Versamag Poly
Manufacturer Model#
Licensed Plumber Certification
Paul LeGault 19756 t 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. o
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 ains and penalties of perjury,
�4-9&
Print Name of Owner q4 Signature of Owner Date
El
Date R fL 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: O
*THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBM I
CITY OF SALEN4
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: 1 Courageous Ct. Unit# 102 #Of units in bldg. 61
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 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 6J10 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 AUG 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, �sKL oT
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, Ah
VV 7Wr)LV- 1Vr QCAI',-T
Print Name of Owner Signature of Owner Date
Date - .
�CEIV
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 SUBMEWRIM
CITY OF !_ :,�
MDPH-CSP Submetering Form,Rev 11-4-16 BOARD OF Hi=r._.LI H
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: 1 Courageous Ct. Unit# 103 #Of units in bldg. 61
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 0 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, r� ;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 ains and penalties of perjury,
Print Name of wner Signature of owner Date
Date L D
El The property has been transferred to owner above and the unit Received EU
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 R
CITY OF SALEM
NMPH-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: 1 Courageous Ct. Unit# 104 #Of units in bldg. 61
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 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"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 AUG 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 p ins and penalties of perjury,
avIia--i nv
Print Name of Owner Si nature of Owner Date
Date r E UH IV 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 SUBMETER
CITY OF SA-,L `,1q
MDPH-CSP Submetering Form,Rev 11-4-16 BOARD OF HL--riLTH
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: 1 Courageous Ct. Unit# 105 #Of units in bldg. 61
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 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 6no
(toilets) gallons per flush(1.6 gpf)
The submetering equipment used to measure the quantity of water used for each dwelling unit and common area must
meet the standards of accuracy and testing of the American Water Works Association or similar accredited association.
A licensed plumber must install the water closets and submetering equipment.
Submetering equipment information: Norgas Metering Technologies Inc Versamag Poly
Manufacturer Model #
Licensed Plumber Certification
Paul LeGault 19756 0 2020
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. 0,Signed under the pains and penalties of perjury, r4o'
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,
Print Name of Owner Signature of Owner ,�.
Date I LZt= V
The property has been transferred to owner above and the unit Received
remains incompliance with the requirements of M.G.L. c. 186, §22 Date: by BOH: SFP 1 8 2do
*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: 1 Courageous Ct. Unit# 106 #Of units in bldg. 61
-City/Town: Salem MA Zip Code: 01970
EQUIPMENT INSTALLATION INFORMATION
105 CMR 410.000 requires the installation of water conservation devices prior to a dwelling unit becoming eligible for the
imposition on tenants of a charge for water and/or sewer. The devices must meet the following specifications:
Showerheads with maximum flow rate not to exceed 2 i,gallons per minute (2.5 gpm)
Faucets with maximum flow rate not to exceed 2 2/10 gallons per minute(2.2 gpm)
Ultra-low flush water closets (toilets)not to exceed 1 6/10 gallons per flush(1.6 gpf)
The submetering equipment used to measure the quantity of water used for each dwelling unit and common area must
meet the standards of accuracy and testing of the American Water Works Association or similar accredited association.
A licensed plumber must install the water closets and submetering equipment.
Submetering equipment information: Norgas Metering Technologies Inc Versamag Poly
Manufacturer Model#
Licensed Plumber Certification
Paul LeGault 19756 AUG 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. ��,j�����
Signed under the pains and penalties of perjury, ��� R 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)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 pain and penalties of perjury,
Af I&K�_ 1�_,A �A&
r nt 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: SFP 1 8 11 0
*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: 1 Courageous Ct. Unit# 109 #Of units in bldfl. 61
City/Town: Salem MA Zip Code: 01970
EQUIPMENT INSTALLATION INFORMATION
105 CMR 410.000 requires the installation of water conservation devices prior to a dwelling unit becoming eligible for the
imposition on tenants of a charge for water and/or sewer.The devices must meet the following specifications:
Showerheads with maximum flow rate not to exceed 2 ''/'gallons per minute (2.5 gpm)
Faucets with maximum flow rate not to exceed 2 2/10 gallons per minute(2.2 gpm)
Ultra-low flush water closets (toilets)not to exceed 1 6/10 gallons per flush(1.6 gpf)
The submetering equipment used to measure the quantity of water used for each dwelling unit and common area must
meet the standards of accuracy and testing of the American Water Works Association or similar accredited association.
A licensed plumber must install the water closets and submetering equipment.
Submetering equipment information: Norgas Metering Technologies Inc Versamag Poly
Manufacturer Model#
Licensed Plumber Certification
Paul LeGault 19756 ALIG 1 ® 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, ;P0,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 pa s and penalties of perjury,
e
Print Name of Owner Signature of Owner D
Dat � x—
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: t BOH: SEP 18 2NO
*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: 1 Courageous Ct. Unit# 110 #Of units in bldg. 61
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.
Submetering equipment information: Norgas Metering Technologies Inc Versamag Poly
Manufacturer Model#
Licensed Plumber Certification
Paul LeGault 19756 �G 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. r�
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 V
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: bv BOH: SEP 1 2� 'Q
*THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBMETERING
CITY OF
MDPH-CSP Submetering Form,Rev 11-4-16 BOARD Cr i,"r',_T 1 H
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: 1 Courageous Ct. Unit# 111 #Of units in bld . 61
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 i=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 WG
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 tinder the pains and penalties of perjury, /v�z 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,
all 1PV
Print Name of Owner Signature of Owner a
11 Date
The property has been transferred to owner above and the unit Received S E P 1 $ 20 0
remains in compliance with the requirements of M.G.L.c. 186, 22 Date: h BOH:
*THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBM6W1 1WSALEM
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: 1 Courageous Ct. Unit# 112 #Of units in bldg. 61
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 6,1°
(toilets) gallons per flush(1.6 gpf)
The submetering equipment used to measure the quantity of water used for each dwelling unit and common area must
meet the standards of accuracy and testing of the American Water Works Association or similar accredited association.
A licensed plumber must install the water closets and submetering equipment.
Submetering equipment information: Norgas Metering Technologies Inc Versamag Poly
Manufacturer —Model#
Licensed Plumber Certification ��au,�
Paul LeGault 19756 10 2020
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,
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 md penalties of perjury,Anwlu& 44A
/
rint Name of Owner Signature of Owner N rJ
rR
—�: v" .
The property has been transferred to owner above and the unit ived
remains in compliance with the requirements of M.G.L. c. 186, '22 Date: OH: SEP 18 20211
*THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBWEQI 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: 1 Courageous Ct. Unit# 113 #Of units in bldg. 61
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 2J10 gallons per minute(2.2 gpm)
Ultra-low flush water closets toilets not to exceed 1 6i'o
(toilets) gallons per flush(1.6 gpf)
The submetering equipment used to measure the quantity of water used for each dwelling unit and common area must
meet the standards of accuracy and testing of the American Water Works Association or similar accredited association.
A licensed plumber must install the water closets and submetering equipment.
Submetering equipment information: Norgas Metering Technologies Inc Versamag Poly
Manufacturer Model#
Licensed Plumber Certification
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, Rolz �^�7 Acf"'—
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
Date
The property has been transferred to owner above and the unit Received SEP 1 20
remains in comp liance 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 SUBMURNP SAL`M
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: 1 Courageous Ct. Unit# 201 #Of units in bldg. 61
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 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.
Submetering equipment information: Norgas Metering Technologies Inc Versamag Poly
Manufacturer Model #
Licensed Plumber Certification
Paul LeGault 19756 AUG 10 202o
Print Name of Plumber License# Date
I certify that(check all that apply):
VI 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, tvo
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 un er the 1pins and penalties of perjury,
4A OzIlk
YIYA
Print Name of Owner Si nature of Owner r
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 20 0
*THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBMUMP 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: 1 Courageous Ct. Unit# 202 #Of units in bldg. 61
City/Town: Salem MA Zip Code: 01970
EQUIPMENT INSTALLATION INFORMATION
105 CMR 410.000 requires the installation of water conservation devices prior to a dwelling unit becoming eligible for the
imposition on tenants of a charge for water and/or sewer. The devices must meet the following specifications:
Showerheads with maximum flow rate not to exceed 2 /'gallons per minute(2.5 gpm)
Faucets with maximum flow rate not to exceed 2 2/10 gallons per minute(2.2 gpm)
Ultra-low flush water closets(toilets)not to exceed 1 6/10 gallons per flush(1.6 gpf)
The submetering equipment used to measure the quantity of water used for each dwelling unit and common area must
meet the standards of accuracy and testing of the American Water Works Association or similar accredited association.
A licensed plumber must install the water closets and submetering equipment.
Submetering equipment information: Norgas Metering Technologies Inc Versamag Poly
Manufacturer Model#
Licensed Plumber Certification
Paul LeGault 19756 AVG 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, /V�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,
I A A A',
Print Name of Owner Si nature o caner •E
Date
The property has been transferred to owner above and the unit Received SEP 1 $ L�'
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 SUBMET"IMGSA` E1k4
MDPH-CSP Submetering Form,Rev 11-4-16 BOARD OF HPAt.-1 I-;
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: 1 Courageous Ct. Unit# 203 #Of units in bld . 61
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.
Submetering equipment information: Norgas Metering Technologies Inc Versamag Poly
Manufacturer Model#
Licensed Plumber Certification AUG 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, /va--z 1z
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 Vains and penalties of perjury,
e
Print Name of Owner i nature of Owner
Date
❑ The property has been transferred to owner above and the unit Received
remains in compliance with the requirements of M.G.L. c. 186, §22 Date: by BOH: SEP 1 8 2O O
*THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBMETERING
CITY OF SAL EM
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: 1 Courageous Ct. Unit# 204 #Of units in bldg. 61
City/Town: Salem MA Zip Code: 01970
EQUIPMENT INSTALLATION INFORMATION
105 CMR 410.000 requires the installation of water conservation devices prior to a dwelling unit becoming eligible for the
imposition on tenants of a charge for water and/or sewer. The devices must meet the following specifications:
Showerheads with maximum flow rate not to exceed 2 /'gallons per minute(2.5 gpm)
Faucets with maximum flow rate not to exceed 2 2/10 gallons per minute(2.2 gpm)
Ultra-low flush water closets(toilets)not to exceed 1 6/10 gallons per flush(1.6 gpf)
The submetering equipment used to measure the quantity of water used for each dwelling unit and common area must
meet the standards of accuracy and testing of the American Water Works Association or similar accredited association.
A licensed plumber must install the water closets and submetering equipment.
Submetering equipment information: Norgas Metering Technologies Inc Versamag Poly
Manufacturer Model#
Licensed Plumber Certification
Paul LeGault 19756 AUG
Print Name of Plumber License#
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. 9
Signed under the pains and penalties of perjury, /6-.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.
SigneQ under the pains and penalties of perjury,
1 &4� I qbb��
Print Name of Owner _ Signature of Owner C94 �,—
Date t_�r— V `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: SEP 19 20FO
*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: 1 Courageous Ct. Unit# 205 #Of units in bldg. 61
City/Town: Salem MA Zi Code: 01970
EQUIPMENT INSTALLATION INFORMATION
105 CMR 410.000 requires the installation of water conservation devices prior to a dwelling unit becoming eligible for the
imposition on tenants of a charge for water and/or sewer. The devices must meet the following specifications:
Showerheads with maximum flow rate not to exceed 2 Y�gallons per minute(2.5 gpm)
Faucets with maximum flow rate not to exceed 2 2/10 gallons per minute(2.2 gpm)
Ultra-low flush water closets (toilets)not to exceed 1 6/10 gallons per flush(1.6 gpf)
The submetering equipment used to measure the quantity of water used for each dwelling unit and common area must
meet the standards of accuracy and testing of the American Water Works Association or similar accredited association.
A licensed plumber must install the water closets and submetering equipment.
Submetering equipment information: Norgas Metering Technologies Inc Versamag Poly
Manufacturer Model#
Licensed Plumber Certification
Paul LeGault 19756 AUG 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, 17jir..0 1z
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 pain and penalties of perjury,
Print Name of'owner Signature of Owner r fir-
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 SUB15T&RAGSALEM
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: 1 Courageous Ct. Unit# 206 #Of units in bld . 61
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 Z/lo gallons per minute(2.2 gpm)
Ultra-low flush water closets toilets not to exceed 1 6i10(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 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,
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 d the pains and penalties of perjury,
r
Print Name of Owner i nature of Owner I ote
Date
The property has been transferred to owner above and the unit Received S E P 18 20 0
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 SUBMItTjfglrJI3 SALEM
BOARD OF HEALTH
MDPH-CSP Submetering Form,Rev 11-4-16