Loading...
1 Carol Way 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: 1 Carol Way Unit# 101 #Of units in bldg. 59 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"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 If tl+ o I-) Paul LeGault 19756 4JV 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 D Date RMEh 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 20211 *THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUB METERING TCITY OF 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: 1 Carol Way Unit# 102 #Of units in bldL. 59 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 '/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. Submetering equipment information: Norgas Metering Technologies Inc Versamag Poly Manufacturer Model# Licensed Plumber Certification Paul LeGault 19756 AUG 1 ® 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 penalties of perjury, /dt . /- & a4A Print Name of Owner Si nature of Owner D Date The property has been transferred to owner above and the unit Received remains in compliance with the 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 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 Carol Way Unit# 103 #Of units in bl&. 59 Citv/Town: Salem MA L, Code: 01970 EQUIPMENT INSTALLATION INFORMATION 105 CMR 410.000 requires the installation of water conservation devices prior to a dwelling unit becoming eligible for the imposition on tenants of a charge for water and/or sewer. The devices must meet the following specifications: Showerheads with maximum flow rate not to exceed 2 1/1 gallons per minute(2.5 gpm) Faucets with maximum flow rate not to exceed 2 2/10 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 ` 0 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, IV4.z R A4&F.* -- 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, �/. — 7// /?—lot Print Name of Owner Signature of Owner e Date The property has been transferred to owner above and the unit Received SEP 1 $ 2020 remains in compliance with the requirements of M.G.L.c. 186, §22 Date: b BOH: *THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBMgWVkGALEM 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 Carol Way Unit# 104 #Of units in bld 59 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 �'� ® � � 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� I;e a& - —_ 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, Jym 1A6J__111__1 Print Name of Owner i=n ture of OwnerEl D Date The property has been transferred to owner above and the unit Received SEP 1 $ 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 SUBWITRN&LEM 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 Carol Way Unit# 105 #Of units in bldg. 59 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 UGGIV, 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, )992-- -/ 1z a4&rV* 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, ,.I I .&A 64_� gh loe Print Name of Owner i nature of,40wner D Date The property has been transferred to owner above and the unit Received SEP 1 $ 202U 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 SUBMfTE5 LEM 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 Carol Way Unit# 109 #Of units in bldg. 59 City/Town: Salem MA Zie 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 z"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 AUG A ® 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, tva"`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)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 mWkno ledge. Signed under the pains and penalties of perjury, ' Print Name of Owner Si na Date AF OnI— 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 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: 1 Carol Way Unit# 111 #Of units in bldg. 59 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 submetcring equipment. Submetering equipment information: Norgas Metering Technologies Inc Versamag Poly Manufacturer d Model# 1 Licensed Plumber Certification Paul LeGault 19756 Wo 1 © 2,0ja 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, paz 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 knowled e. Signed unde he pains and penalties of perjury, 't�le - 6x, 4 Print Name of Owner ignature of wner 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: SEETP 1 8 202 *THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUB II�II ETERI 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: 1 Carol Way Unit# 112 # Of units in bldg. 59 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 /�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 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 1® 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, ;VOW 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 _iynature 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 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 Carol Way Unit# 113 #Of units in bldg. 59 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 Vi 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 Uersamag Poly Manufacturer Model# Licensed Plumber Certification Paul LeGault 19756 (p� 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 ie pains and penalties of perjury, � z Print Name of Owner SiLmature of Owner n Date The property has been transferred to owner above and the unit Received remains in compliance with the requirements of M.G.L. c. 186, 22 Date: b BOH: SEP 18 2029 *THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBIL.ETERTY-O FNTALEM BOARD OF HEALTH NMPH-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 Carol Way Unit# 201 #Of units in bldg. 59 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 4AUG 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, /Vi-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 under t pains andpenalties of perjury, Print Name of Owner Si=,,nature of Owner Date The property has been transferred to owner above and the unit Received remains in compliance with the requirements of M.G.L. c. 186, §22 Date: by BOH: SEP 18 20ZO *THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUMTERING SAl_EM BOARD OF HEALTH 1VIDPH-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 Carol Way Unit# 202 #Of units in bldg. 59 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 spedifications: 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. Submetering equipment information: Norgas Metering Technologies Inc Versamag Poly Manufacturer Model# Licensed Plumber Certification Paul LeGault 19756 ►�® 20 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, /Vo-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 t e pains and penalties of perjury, 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 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 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 Carol Way Unit# 203 #Of units in bldg. 59 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 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"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 902020 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 he pains and penalties of perjury, Print Name of Owner Si nature of Owner A 6&k- 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: bN sox: SEP 18 20 *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 Carol Way Unit# 204 #Of units in bldL. 59 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. Submetering equipment information: Norgas Metering Technologies Inc Versamag Poly Manufacturer Model # Licensed Plumber Certification Paul LeGault 19756 �� ® 2�ZQ 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, 1V�L ;e kz� SiLi 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, Print Name of Owner Mgryiure 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 2020. *THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBM. TEgIF SALEM BOARDVOF 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 Carol Way Unit# 205 #Of units in bldy. 59 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. Submetering equipment information: Norgas Metering Technologies Inc Versamag Poly Manufacturer Model# Licensed Plumber Certification Ant 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 t pains and penalties of perjury, 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 sox: SEP 18 2020 *THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBMETERINCdLEM BOARD OOOFFFSHEALTH 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 Carol Way Unit# 206 # Of units in bl&. 59 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. 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): 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. 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, Print Name of Owner Signature of Owner Date The property has been transferred to owner above and the unit Received SEP 18 2020 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 SUBVIVEMISALEM 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 Carol Way Unit# 207 #Of units in bldg. 59 City/Town: Salem MA Zip Code: 01970 EQUIPMENT INSTALLATION INFORMATION 105 CMR 410.000 requires the installation of water conservation devices prior to a dwelling unit becoming eligible for the imposition on tenants of a charge for water and/or sewer. The devices must meet the following specifications: Showerheads with maximum flow rate not to exceed 2 1/1 gallons per minute(2.5 gpm) Faucets with maximum flow rate not to exceed 2 2/10 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 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. 'fJ 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)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. Sigydunr the pains and penalties of perjury, /l/ Print Namf of Owner 'tig ur o D 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 18 202 *THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUB�WFMALEM 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 Carol Way Unit# 208 #Of units in bldg. 59 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. 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, /Vo-z )F o 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 tl pains and penalties of perjury, am Print ame of Owner natu f Own El Date OF ri Lj5Jkr!-:! M X rE D The property has been transferred to owner above and the unit Received SEP 18 2020 remains in compliance with the requirements of M.G.L. c. 186, §22 Date: by. BOH: *THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBMI-YEQWLEM 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 Carol Way Unit# 209 #Of units in bldg. 59 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. Submetering equipment information: Norgas Metering Technologies Inc Versamag Poly Manufacturer Model# Licensed Plumber Certification G p,g Paul LeGault 19756 SLt��7 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. Signed under the pains and penalties of perjury, IVIO"`Z 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 under he pains and penalties of perjury, d1v Print Name of Owner Si nature o Owner BEG FIVED El Date The property has been transferred to owner above and the unit Received SEP 18 202 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 SUBloftTYMALEM BOARD OF HEALTH NMPH-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 Carol Way Unit# 210 #Of units in bldg. 59 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 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 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 he pains and penalties of perjury, } Print Name of Owner. Si gna e of Owner RECEWED Date The property has been transferred to owner above and the unit Received SEP 18 202 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 SUBMff f 60f�ALEM 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 Carol Way Unit# 211 #Of units in bldg. 59 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 A116 10a 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 penalties of perjury, .,Z - — �?,//Zze Print Name of Owner Signature of Own r) Date 9 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 sox: SEP 18 202, *THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUB'FfEMALEM 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 Carol Way Unit# 212 #Of units in bldg. 59 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"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 #qq ��gg Licensed Plumber Certification i AW 1 ® L®L 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, �Iw� 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 pain and penalties of perjury, l Print Name of Owner Signature of Owner Date Date The property has been transferred to owner above and the unit Received RE C 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 SUB 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 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 Carol Way Unit# 213 #Of units in bldg. 59 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 v'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. Submetering equipment information: Norgas Metering Technologies Inc Versamag Poly Manufacturer Model # Licensed Plumber Certification ® [ G q�agQ 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. 9 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, F / l Print Name of Owner Signature of Owner RECEIVED El 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: by BOH: *THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBILAftV�JIPI§ALEM 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 Carol Way Unit# 301 #Of units in bldg. 59 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. Submetering equipment information: Norgas Metering Technologies Inc Versamag Poly Manufacturer Model # Licensed Plumber Certification Paul LeGault 19756 AW I® 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 and the pans and penalties of perjury, Print Name of Owner Signature bt Owner D Date RECEIVE 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 SUB MMNALEM 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 Carol Way Unit# 302 #Of units in bldg. 59 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 Yz 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 W10 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. 19 Signed under the pains and penalties of perjury, oz 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 infornation 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 remains in compliance with the requirements of M.G.L. c. 186, §22 Date: by BOH: SEPR1 8202 *THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBI ff7,E OFG SALEM N4DPH-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 Carol Way Unit# 303 #Of units in bldg. 59 -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 ® '�oZo 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 and r the pain and penalties of perjury, •Print Name of Owner Si nature of Owner Date The property has been transferred to owner above and the unit Received remains in compliance with the requirements of M.G.L. c. 186, §22 Date: by BOH: SEP 18 202.7 *THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUB11�f flNl%ALEM BOARD OF HEAL-CH 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 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 Carol Way Unit# 304 #Of units in bldg. 59 CA /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 10 2020 Paul LeGault 19756 id Print Name of Plumber License# Date I certify that(check all that apply): ®I have installed the submetering equipment listed above in accordance with accepted plumbing standards. ❑ I have installed one or more water closets not exceeding 1.6 gallons per flush. ®Determined that existing water closets do not exceed 1.6 gallons per flush. ❑ The plumbing permit issued by the city/town, if required, is attached. ❑ Dwelling unit is connected directly to a meter installed by a water company and, in accordance with M.G.L. c. 186, § 22(p),does not require the installation of a submeter. Signed under the pains and penalties of perjury, V�� Signature of Licensed Plumber Property Owner Certification I certify that: (1)This dwelling unit is eligible for the imposition on the tenants of a charge for water and/or sewer usage in accordance with the water submetering law(MGL c. 186, §22); (2)All showerheads,faucets, and water closets in this dwelling unit are water conservation devices that meet the standards specified above; (3)The water submeter measuring the use of water in the dwelling unit was installed by a licensed plumber and is in compliance with the standards specified above, or the water meter measuring the use of water in this dwelling unit was installed by a"water company" as defined in M.G.L. c. 186, § 22; (4)The water meter or submeter measures the water usage exclusive to this unit; (5)1 will provide to the tenants of this dwelling unit, prior to occupancy,a written rental agreement that clearly provides for the separate charging of water and/or sewer service, and a copy of this certification form; (6)That all information included on this certification is true and accurate to the best of my knowledge. Signed un er the pains and penalties of perjury, Print Name of Owner i nature of Owner RbLe FIVED Date The property has been transferred to owner above and the unit Received SEP 18 2 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 SUBrtFnI�JP4%ALEM BOARD OF HEALTH NIDPH-CSP Submetering Form,Rev 11-4-16 MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH SUBMETERING OF WATER AND SEWER CERTIFICATION FORM *In accordance with M.G.L. c. 186, §22 and 105 CMR 410.000: Minimum Standards of Fitness for Human Habitation (State Sanitary Code Chapter II),the following dwelling unit is eligible for the imposition on the tenants of a charge for water and/or sewer service. PROPERTY INFORMATION Address: 1 Carol Way Unit# 305 #Of units in bldg. 59 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. Submetering equipment information: Norgas Metering Technologies Inc Versamag Poly Manufacturer Model# Licensed Plumber Certification A Paul LeGault 19756 10 202u Print Name of Plumber License# Date 1 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, ��"•� aGd Signature of Licensed Plumber Property Owner Certification I certify that: (1)This dwelling unit is eligible for the imposition on the tenants of a charge for water and/or sewer usage in accordance with the water submetering law(MGL c. 186, §22); (2)All showerheads, faucets, and water closets in this dwelling unit are water conservation devices that meet the standards specified above; (3)The water submeter measuring the use of water in the dwelling unit was installed by a licensed plumber and is in compliance with the standards specified above,or the water meter measuring the use of water in this dwelling unit was installed by a"water company" as defined in M.G.L. c. 186, § 22; (4)The water meter or submeter measures the water usage exclusive to this unit; (5)I will provide to the tenants of this dwelling unit, prior to occupancy, a written rental agreement that clearly provides for the separate charging of water and/or sewer service, and a copy of this certification form; (6)That all information included on this certification is true and accurate to the best of my knowledge. Signed u der the ins and penalties of perjury, Print Name of Owner Signature of(_ er paig 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: SP *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 Carol Way Unit# 306 #Of units in bldg. 59 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 /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 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 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, �� z4sm 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, 1� 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: bv BOH: *THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBMETERING CITY OF SALEM MDPH-CSP Submetering Form,Rev 11-4-16 BOARD OF HEALTH MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH SUBMETERING OF WATER AND SEWER CERTIFICATION FORM *In accordance with M.G.L. c. 186, § 22 and 105 CMR 410.000:Minimum Standards of Fitness for Human Habitation (State Sanitary Code Chapter II),the following dwelling unit is eligible for the imposition on the tenants of a charge for water and/or sewer service. PROPERTY INFORMATION Address: 1 Carol Way Unit# 307 #Of units in bldg. 59 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. Submetering equipment information: Norgas Metering Technologies Inc Versamag Poly Manufacturer Model # Licensed Plumber Certification VG Al 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, 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 pai and penalties of perjury, Print Name of Owner 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, §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: 1 Carol Way Unit# 308 #Of units in bl&l. 59 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. Submetering equipment information: Norgas Metering Technologies Inc Versamag Poly Manufacturer Model # Licensed Plumber Certification p� Paul LeGault 19756 c 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�"`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 and.,r the pains and penalties of perjury, Print Name of Owner Sig ature of 4vner p— A 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: bv BOH: SEP 18 2V, *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 Carol Way Unit# 309 #Of units in bldg. 59 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 !/�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 W���i'�7 7 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, �~`z � 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 he pains and penalties of perjury, Print Name of Owner i 44—. ature of Own � 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: SEP 18 20:'0 *THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBMMTRIIVGSALEM 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 Carol Way Unit# 310 #Of units in bld . 59 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#A��� Licensed Plumber Certification � �j ® [ Paul LeGault 19756 1� 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. ��jj Signed under the pains and penalties of perjury, /Vcu-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, 0&4c�l Print Name of Owner Si nature of Owner r 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 1 $ 20 *THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUB TERING TITY OF 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: 1 Carol Way Unit# 311 #Of units in bld . 59 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 LUZU 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, /VI-z R Az -_ 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 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 sox: SEP 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 It-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 Carol Way Unit# 312 #Of units in bldg. 59 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. 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, /V� 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)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, 0__2 "Ve ,. Print Name of Owner gignaturV of Owne -''i 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 Box: SEP 18 202 *THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBRNTM, G.. .., BOARD OF h;_i'.LFH 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 Carol Way Unit# 313 #Of units in bldg. 59 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 2f 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 0 20? 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, IS iyna ure oT L7e7n 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 undytheains and penalties of perjury, l 2 Print Name of Owner Signature of Owner t D Date l = s 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 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 Carol Way Unit# 401 #Of units in bldg. 59 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 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 110 2D24 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, Rim 1z kz 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)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 tl pains anL penalties of perjury, Print Name of Owner Signature of Owner Qatp 11 Date Y 1= - 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: 1 Carol Way Unit# 402 #Of units in bldg. 59 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 /z gallons per minute(2.5 gpm) Faucets with maximum flow rate not to exceed 2 2"0 gallons per minute(2.2 gpm) Ultra-low flush water closets(toilets)not to exceed 1 6/10 gallons per flush(1.6 gpf) The submetering equipment used to measure the quantity of water used for each dwelling unit and common area must meet the standards of accuracy and testing of the American Water Works Association or similar accredited association. A licensed plumber must install the water closets and submetering equipment. submetering equipment information: Norgas Metering Technologies Inc Versamag Poly Manufacturer Model# Licensed Plumber Certification 4 0 n2p 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)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 Signature of wn°� a El Date `— L:I 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: by BOH: SEP 19 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: 1 Carol Way Unit# 403 #Of units in bldg. 59 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 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 pai and penalties of perjury, • /� zd Print Name of Owner Si,_nature of Ow_neCtt� Date °�T � The property has been transferred to owner above and the unit 1 Received remains in compliance with the requirements of M.G.L. c. 186, §22 Date: by BOH: SEP 1 8 20 0 *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 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 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 Carol Way Unit# 404 #Of units in bldg. 59 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 is 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 gallops 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 r VQ 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, lvo-e R Si4nature 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 certi ation form; (6)That all information included on this certification is true and accurate to the best of my kno wle ge. Signed under th pains and penalties of perjury, Print Name of Owner Si gnat e of Owner P40X,,.r I ItD Date — 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: SEP 18 202 *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 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 Carol Way Unit# 405 #Of units in blds_>. 59 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. Submetering equipment information: Norgas Metering Technologies Inc Versamag Poly Manufacturer Model# Licensed Plumber Certification Paul LeGault 19756 1.10 � Print Name of Plumber License# Date I certify that(check all that apply): ®I have installed the submetering equipment listed above in accordance with accepted plumbing standards. ❑ I have installed one or more water closets not exceeding 1.6 gallons per flush. ®Determined that existing water closets do not exceed 1.6 gallons per flush. ❑The plumbing permit issued by the city/town, if required, is attached. ❑Dwelling unit is connected directly to a meter installed by a water company and, in accordance with M.G.L . c. 186, §22(p), does not require the installation of a submeter. Signed under the pains and penalties of perjury, ;Po"z I;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)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 e pains and penalties of perjury, Print Name of Owner Signature of Owner Date 13 Date y`_ VL- 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 TERIN IV 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 Carol Way Unit# 406 #Of units in bldg. 59 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 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, lvo-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)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 certificati fo in,;, (6)That all information included on this certification is true and accurate to the best of my knowledge. Signed under e pain nd penalties of perjury, Print Name of Owner J Signature of Owner , 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: SFP 70h *THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBMETERING CITY OF SALEM MDPH-CSP Submetering Form,Rev H-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 Carol Way Unit# 407 #Of units in bldg. 59 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. Submetering equipment information: Norgas Metering Technologies Inc Versamag Poly Manufacturer Model# Licensed Plumber Certification qq e} 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 tl pains and penalties of perjury, 4 � — // 1-26 Print Name of Owner Si nature of Owner 11 r ° Date r`� 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 2010 *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 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 Carol Way Unit# 408 #Of units in bldg. 59 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 AM i o ma 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� .1EP �� 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 112 "// - �ALI - 7 Print Name of Owner _ Signature of Owner Date +Y== L= v9 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: UP 19 7010 *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 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 Carol Way Unit# 409 #Of units in bldg. 59 City/Town- Salem MA Zip Code: 01970 EQUIPMENT INSTALLATION INFORMATION 105 CMR 410.000 requires the installation of water conservation devices prior to a dwelling unit becoming eligible for the imposition on tenants of a charge for water and/or sewer. The devices must meet the following specifications: Showerheads with maximum flow rate not to exceed 2 '1/1 gallons per minute(2.5 gpm) Faucets with maximum flow rate not to exceed 2 2/10 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 rFAUG 10 20 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 unde he pains and penalties of perjury, X Ao,f, ?///Z,) Print Name of Owner 15ignalure of Owner F i 1j In 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 SUBMEITRGSALEM 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 Carol Way Unit# 410 #Of units in bldg. 59 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. Submetering equipment information: Norgas Metering Technologies Inc Versamag Poly Manufacturer Model# Licensed Plumber Certification lE�a Paul LeGault 19756 W ® 10279. 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, 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, KIIA6 Print Name of Owner Signature of Owner nn Date RF L ED E y 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: b .BOH: SEP 18 ZO O *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: 1 Carol Way Unit# 411 #Of units in bldg. 59 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 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. Submetering equipment information: Norgas Metering Technologies Inc Versamag Poly Manufacturer Model# Licensed Plumber Certification Paul LeGault 19756 AVG 10 20 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 he pains and penalties of perjury, Print Name of Owner Signature of Owner CC Date ice : 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: by BOH: U *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 Carol Way Unit# 412 #Of units in bldg. 59 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 AUG 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 he pains and penalties of perjury, under // l 2 Print Name of Owner Signature of Owner 00 Date The property has been transferred to owner above and the unit Received S E P 1 8 2 20 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 SUBMIJW 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 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 Carol Way Unit# 413 #Of units in bldg. 59 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"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 F� - O ® 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 he pains and penalties of perjury, r Print Name of Owner Vsignature of Owner 7 1 i 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 sox: SEP 18 20'0 *THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBM6TI ARINGSALEM BOARD OO O HEALTH FFF 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: 1 Carol Way Unit# 503 #Of units in bldg. 59 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. Submetering equipment information: Norgas Metering Technologies Inc Versamag Poly Manufacturer Model# Licensed Plumber Certification AUG 18 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, C4 / lQ 'Print Name of Owner Signature of OwnerEl Date The property has been transferred to owner above and the unit Received S E P 1 8 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 SUB"�IWWtALEM BOARD OF HEALTH NIDPH-CSP Submetering Form,Rev 11-4-16 MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH SUBMETERING OF WATER AND SEWER CERTIFICATION FORM *In accordance with M.G.L. c. 186, § 22 and 105 CMR 410.000: Minimum Standards of Fitness for Human Habitation (State Sanitary Code Chapter II),the following dwelling unit is eligible for the imposition on the tenants of a charge for water and/or sewer service. PROPERTY INFORMATION Address: 1 Carol Way Unit# 504 #Of units in bldg. 59 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 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 AUG2020 Paul LeGault 19756 �L7 1J 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, a� 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 submetcring 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, ? / 2d Print Name of Owner Signature of Owner �- Date El The property has been transferred to owner above and the unit Received SEP 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 SUBMETRI&FC.,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: 1 Carol Way Unit# 505 #Of units in bldg. 59 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. Submetering equipment information: Norgas Metering Technologies Inc Versamag Poly Manufacturer Model# Licensed Plumber Certification I taw2020 Paul LeGault 19756 AUGt� 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. p1 Signed under the pains and penalties of perjury, Sit,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 ie pains and penalties of perjury, Print Name of Owner ignatd re of Owner r— y 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 Box: 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 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 Carol Way Unit# 506 #Of units in bldg. 59 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. Submetering equipment information: Norgas Metering Technologies Inc Versamag Poly Manufacturer Model# Licensed Plumber Certification Paul LeGault 19756 f. ® 2,a20 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, tva-z z zj � 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 VIAlirrature.of Owner Date171 It.b 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: UP 1 8 760 *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: 1 Carol Way Unit# 507 #Of units in bldg. 59 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 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, lv/-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/ Print Name of Owner Si nature of wner If E E Date El The property has been transferred to owner above and the unit Received SEP 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 SUBM§Tf-f 1810SALEM 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 Carol Way Unit# 508 #Of units in bldg. 59 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 6/10 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 � Paul LeGault 19756 -g 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, /Vo-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 Name of Owner Si n ture 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 20"1 *THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBMET-TMFGSA1 . 30ARD OF HEnL_,, 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 Carol Way Unit# 509 #Of units in bldg. 59 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 FA 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, /Vo-z 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 enalties of perjury, Print Name of Owner wSignattirelof Owner Date Date 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: b BOH: n 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 Carol Way__ Unit# 510 #Of units in bldg. 59 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 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. Submetering equipment information: Norgas Metering Technologies Inc Versamag Poly Manufacturer Model# Licensed Plumber Certification Rx Paul LeGault 19756lJ 10 �� Print Name of Plumber License# Date I certify that(check all that apply): ®I have installed the submetering equipment listed above in accordance with accepted plumbing standards. ❑ I have installed one or more water closets not exceeding 1.6 gallons per flush. ® Determined that existing water closets do not exceed 1.6 gallons per flush. ❑ The plumbing permit issued by the city/town, if required, is attached. ❑ Dwelling unit is connected directly to a meter installed by a water company and, in accordance with M.G.L . c. 186, § 22(p), does not require the installation of a submeter. d Signed under the pains and penalties of perjury, ;9µe 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 he pains and penalties of perjury, Print Name of Owner Si nature of Owner ,axe Date Li I t 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: *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: 1 Carol Way Unit# 511 #Of units in bldg. 59 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 2/10 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 ® 2mp0 Paul LeGault 19756 11�17Y�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 knowled Signed under the pains and penalties of perjury, /ze 1 Zd Print Name of Owner Si nature of OwnerEl _ Date IL L--I "' 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: SLP 1 8 7C U *THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBMETERING CITY OF SAL&0 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 Carol Way Unit# 512 #Of units in bld . 59 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 � L��� 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, pa-e 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 and the pains and penalties of perjury, Print Name of Owner S nau e o Owner Date H 1z C.,LE I v E D The property has been transferred to owner above and the unit Received remains in compliance liance with the requirements of M.G.L. c. 186, §22 Date: by BOH: A 2172n *THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBMETERING CITY O MDPH-CSP Submetering Form,Rev 11-4-16 BOARD 0i-. ' ' '"=' +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 Carol Way Unit# 513 #Of units in bldg. 59 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. submetering equipment information: Norgas Metering Technologies Inc Versamag Poly Manufacturer Model # Licensed Plumber Certification AUG 192 20 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. f7 op 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 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: SEP0 *THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBMETERING CITY OF S,"; .� ,1 MDPH-CSP Submetering Form,Rev 11-4-16 BOARD OF i-1L. ,L F H