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Water submeter certificates - Units in the 3s MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH SUBMFTERING OF WATER AND SEWER CERTIFICATION FORM *In accordance with M.G.L.c.196.§22 and 105 CMR 410.000.Minim-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.f - PROPERTY INFORMATIO___N Address: 205 H hland Ave Un1t 95308 24 Ci frown:.Salem MA zip code:01970 EQUIPMENT INSTALLATION INFORMATION 105 CMA 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: Showetheads with maximum flow rate not to exceed 2%fallons per minute(2.S gpm) Faucets with maximum flow rate not to exceed 2 a" gallons per minute(22 gpm) Ultra-low flush water closets(toilets)not to exceed l"'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 Wodcs Association or similar accredited association. A licensed plumber must install the water closets and submeteting equipment. Submeteuing equipment information: Master Meter Flexible Axis Manufacturer Model 0 Licensed Plumber Cerdflicatlon Joseph Bellefeuille - 9793 12-16-2019 Print Name of Plumber License# v m Date I rectify that(check all that apply): Rn PI 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 Bush. Determined that existing water closets do not exceed 1.6 gallons per flush. The plumbing permit issued by the city/town.if requited,is attached Q Dwelling unit is connected directly to a meter installed by a water company and,in accordance with M.G.L.c.186,122(p),does not require the installation of a submeter. Signed under the pains and penalties of pcxjury, Si Lute or Licensed Plnnber - - Property Owner Certification I certify that:(1)This dwelling unit is eligible for the imposition on the tenants of a charge fete 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 LCG.L,c.186,122; (4)The water meter or submetcr 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 cer iflcadon is true and accurate to the best of my knowledge. Signed under the pains and penalties of pc:jury, Print Name of Owner Sinenature of Owner D Date L' ❑The property has been transferred to owner above and the unit Received remains in compliance with the Leguirements of M.G.L.c. 186,122 Date: by BO *THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING S 8 MDPH-CSPSubnreteringForm,Rev 11.4-16 CITY OF SALEM BOARD OF HEALTH MASSACErUSETTS DEPARTMENT OF PUBLIC HEALTH SUBMETERING OF WATER AND SEWER CERTIFICATION FORM *In accordance with M.G.L.c.186,§22 and 105 CMR 410AW.Minimum Standards of Fitness for Human Habitation (State Sanitary Code Chapter H),the following dwelling unit is eligible for the imposition an the tenants of a charge for water and/or sewer service. _ PROPERTY INFORMATION Address: 205 Highland Ave 07 24 c rrown: Salem MA Zip Code:01970 EQUIPMENT INSTALLATION INFORMATION 105 CMR 410.000 requites the installation of water conservation devices prior to a dwelling unit becoming eligible for the imposition an tenants of a charge for water and/or sewer.The devices must meet the fallowing speciScatious: Sbowetbeads with maximum flow rate not to exceed 2%gallons per minute(2.5 Spin) 4 Faucets with maximum flow rate not to exceed 2 gallons per minute(2.2 gpm) j Ultra-low flush water closets(toilets)not to exceed 1 Asa gallons per flush(l.6 gpf) The submetering equipment used to measure the quantity of water used for each dwelling unit and common amen must meet the standards of accuracy and testing of the American Water Works Association or similar accredited association. A licensed phanber must install the water closets and submetering equipment. Submetering equipment information: Master Meter Flexible Axis Manufacturer Madel# Licensed Plumber Certification — Joseph Beliefeu_iile 9793 12-15 2019 Print Name of Plumber License# Date I cartify that(check all that apply): ME 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 cityAawn,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 of Licrosed Plumber Property Owner Certification 1 I certify that(1)'Mis dwelling unit is eligible for the imposition on the tenants of a charge for water and/or sewer usage in accordance with the water submetaring law(MGL c.I86.§22);(2)All showerheads,faucets,and waux closets in this dwelling unit are water conservation devices that meet the standards specified above;(3)The water submater 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)l wM 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 fort;(6)That all information included on this certification is true and accurate to the beg of my knowledge. Signed trader the pains and penalties ofperjtuy, 2-114 Act Print Name or Owtur, Sienatum of Owner T Date O no properly iris been transfenzd to owner above and the unit Received remains in 2MEliance with the rc=auirements of M.G L c. 186§22 Date: b $OH:FEB 21 202 'THIS FORM MUST BE FILED WITH 7HE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SU6MEr1ERING CITY OF SALEM MDPH-CSPSubmeteringForm,Rcv 11.4-16 BOARD OF HEALTH MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH SUBMIETERENG 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 SaWtN7 Code Chapter II),the following dwelling unit is eligible for the imposition on the tenants of a charge for water an�l/or�eoare�service. PROPERTY INFORMATION Address: 206 Highland Ave Un. .. 306 #Gfun 1nh1dg-24 Ci /Town: Salem MA Zi Cade:01970 EQIIIPM ENT INSTALLATION INFORMATION 105 CMR 410.000 requites the installation of water conservation devices prior to a dwelling unit becoming eligible for the imposition an tenants of s charge far water and/or sewer.The devices must meet the following specifications: Showe dmds with maximum flow rate not to exceed 2 u alIons per minute(2.5 rpm) Faucets with maximum flow rate not to exceed 2 gallons per minute(2 2 rpm) Ultra-low flush water closet(toilets)not to exceed l de°gallons per flush(1.6 gpf) The submatering 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 similaraccredited association. A licensed plumber must install the water closets and submetering equipment. Subm etexing equipment information: Master Meter• Flexible Axis _-- Manufacturer Model# Licensed Plumber Certificatloa Joseph Belleieunle 9793 12-16-2019 Print Name of Plumber L.icemse# Date I exetiFy that(check all that apply): 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 cityltown,ifrequired,is attached. Dwelling unit is corrected 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 ofa submeter. Signed under the pains and penalties of per uty, --4n /1 C C: . f, -- S' aroma of L'ecgmsed htmbe:r Property Owner Certification (certify that:(1)This dwelling unit is eligible for the imposition on the tenants of a chap 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 am water conservation devices that meet the standards specified above;(3)The water submo ter measuring the use of water in the dwelling twit 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.186,122; (4)The water meter or subme ter 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 forum;(6)That all information included on this certification is true and accurate to the best of my knowledge. Signed under the pains and penalties ofpadury, Print Name of Owner Sinnattmre of Owner E DE 1 D Date I7 The property has been transferred to owner above and the unit Received remains in 2Mliance with the requirtments of M.G.L,e:. M 22 Date: by$OH *THIS FORM MUST BE FILED iMTH THE LOCAL BOARD OF HEALTH PRIOR TO iNITiAi'ING SUBME ERING CITY OF SALEM MDPH-CSP Submcicdag Form,Rev 11-4-16 BOARD OF HEALTH MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH SUBl4IETERING OF WATER AND SERVER CERTIFICATION FORM 'In accordance with M.G.L.m 196,§22 and 105 CMR 410.000:Minimum Standards of Fitness for Human Habitation (State Sanitary Code Chapter II),the fallowing dwelling unit is eligible for the imposition an the tenants of a charge for water and/or sewer Service. _ PROPERTY INFORMATION Address: 205 H' hiarttl Ave 11ni, 3305 Naunim in hid, 24 Ci mown: Salem MA Zip Code:01970 EQOMbW.NT INSTALLATION INFORKA13ON 105 CMR 410.000 requites 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: Showetheads with maximum flow rate not to exceed 2:jAlons per minute(L5 gpm) Faucets with maximum flow rate not to exceed 2 gallons per minute(2.2 gpm) Ultm-low flush water closets(toilets)not to exceed 1 Wd gallons per flush(l.6 gp0 The submetering equipment used to treasure 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 similaraccredited association. A licensed plumber must install the water closets and submeteting equipment. Submetering equipment i0brmation: faster Meter Flexible Axis Manufacturer Model# Licensed Pkimber Certification Joseph Bellefeuilie 9793 _12-16-2019 Print Name of Plumber License# Date I certify that(check all that apply): XII have installed the submetering equipment fisted 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,ifrequh4 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 paints and penalties ofpedury, ' _ Si turc of 'tensed bar Property Owner Certilleatfon I certify that:(1)This dwelling unit is eligible for the imposition on the tenants of a charge far water and/or sewer usage in accords=with the water submetering law(MGL c.186,§22);(2)All showetlicads,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.18C§22; (4)The water meter or submeter measures the water usage exclusive to this unit;(5)1 will provide to die 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 fbim;(6)That all information included on this certification is none and accurate to the best of cry knowledge. Signed under the pains and penalties of pe dury, a, z1� a s H k4 Print Name of Owner Si>:natum ofOwner Date 13 The property has been:transferred to owner above and the unit Received terrains in compliance with the roanitements of M.G.L.c.186,_§g_ Date: —]by BOH: U 'THIS FORM MUST BE FILED VdITH THE LOCAL BOARD OF HEALTH PRIOR TO iNff1ATING SUIIMET CITY OF SALEM MDPH-CSPSubmeteringFarm,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.196,§22 and 105 CMR 410.000:Minianom Standards of Fitness for Human Habitation (State Sanitary Code Chapter II),the fallowing dwelling unit is eligible for the imposition an the tenants of a charge for water and/or sc-.=service. PROPERTY INFORMATYON Address: 205 Highland Ave IM11 ON04 nift in hiftor 24 Ci /Town: Salem MA Zip Code:01970 EQUIPMENT EMALLATION INFORMATION 105 CMR 410.000 requires the installation of water conservation devices prim to a dwelling unit becoming eligible for the imposition on tenants of a charge forwater and/or sewer.The devices must meet die following specifications: Sbowerheads with maximum flow rate not to exceed 2"gallons per minute(2.5 gpm) Faucets with maximum flow rate not to exceed 2 gallons per minute(2.2 gpm) Ultra-low flush water closets(toilets)not to exceed I bf io 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 Wotks Association or similar accredited association. A licensed plumber must install the water closets and submetering equipment. Submetering equipment information: Master deter Flexible Axis Manufacturer Model# LAcensed Plumber Certification Joseph Bellefeuille 9793 12-16-2019 Print Name of Plumber License# Date I centnfy 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 Dust. Determined that existing water closets do not exceed 1.6 gallons per flush. The plumbing permit issued by the city/town,ifrequired,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, � n q, Sivarature f Uoensed PNrnber Property Owner CertMeadon certify that:(1)This dwelling unit is eligible for the imposition on the tenants of a dune for water and/or sewer usage in accordance with the water submttering law(MGL c. l B6,§22);(2)All showerhesds,faucets,and water closets in this dwelling unit are water conservation devices that meet the standards specified above;(3)The water submater 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)l 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 tare and accurate to the best of my knowledge. Signed under the pains and penalties of perjury, a4- fcs� e- 4 0 (L/' /m Print Name of Owner Signature of Owner t IE M D Date The property has been transferred to owner above and the unit Received remains is compliance with the mqjMMents of M.G.L.a 166 22 Date: by BOH: 'THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INMATING SUBMETERING CITY OF SALEM MDPH-CSPSubmetoing 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 IM the following dwelling unit is eligible for the imposition an the tenants of a charge for :rater audlor sewer service. PROPERTY INFORMATION - Address: 205 i-ll hlant:l Ave 03 24 Ci g wa: 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 fallowing specifications: Showerbeads with maximum flow rate not to exceed VA gallons per minute(2.5 gpm) Faucets with maximum flow rate not to exceed 2 m gallons per minute(2.2 gpm) Ultra-tow Bush water closets(toilets)not to exceed 1 6"a 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 infamation: Master Meter Flexible Axis Manufacturer Model# F— — — Licensed Plumber Certification Jweph Belieteuilie _ 9793 12-16-2019 Print Nano 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. '0 Dwelling unit is connected directly to a meter installed by a water company and,in accordance with M.G.L.r«186,§22(p),does not require the installation of a submeter. Signed under the pains and penalties of perjury, — _ Si tare Of Licensed Plumber Property Owner Certiticatlen I certify that:(I)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.186,122; (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 far the separate charging o€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 army knowledge. Signed under the pains and penalties of perjury, Print Name of Owner Si shire of O er Date C3 Tbc property has been transferred to owner above and the unit lteceivcd FEB 21 20 0 renmaias in L:a liance with the requirements of M.G.L.c. 186 22 Date: b BOH: "THIS FORM MUST BE FILED WITH THE LOCAL.BOARD OF HEALTH PRIOR TO INITIATING SU TE 11UGrSA LE.Ul MDPH-CSP Submetering Form,ttev l l-4-iti BOARD OF HEALTH MASSACEUSETTS DEPARTMENT OF PUBLIC HEALTH SUBMZITJMG OF WATER AND SEWER CERTIFICATION FORM *In accordance with M.G.L.c.186,§22 and 105 CMR 410.000.Minimum Standards of Fitness far 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 sew--service. PROPERTY INFORMATION Address: 205Highland Ave Unit 4,3302 24 ci rrown: Salem MA Zip Code:01970 EQUIPbEM 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: Showerheade with maximum flow rate not to exceed 2 x fallons per minute(2.5 Spin) Faucets with maximum flow rate not to exceed 2' gallons per minute(22 gpm) Ultra-low Bush water closets(toilets)not to exceed 16"Q 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: Master Meter Flexible Axis Manuf etuti:r Model# — -- - - - Licensed Plumber C:er dflcsbon Joseph Bellefeuille �71 _ 12-18-2019 - — Print Name of Plumber License# Date I certify that(check all that apply): Ell have Installed the submetering equipment fisted 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 cityhown,if required,is attached ❑Dwelling unit is connected directly to a metes installed by a water company and,in accordance with M.G.L.c.186.1 22(p),does not require the installation of a submeter. Signed under the palm and penalties of perjury, � 'L�- -�- sigzature drLicansed Plumber Properly Owner Certification t certify that:(1)This dwelling unit is eligible for the imposition on the tenants of a charge Cur 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 omit 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`%vatcr company" as defined in M.G.L.c.186,§22; (4)The water meter or submeter measures the water usage exclusive to this unit;(5)I will provide to the tenants of this dwelling unit,prior to occupancy,a written rental agreement that clearly provides for the separate charging of water and/or sewer service,and a copy of this certification form;(6)That all information included on this certification is true and accurate to the best of my knowledge. Signed under the pains and penalties of perjury, Q 1.,- 11 ai X—�,+ (z 0 Print Name of Owner Sienature ofOwner D Date 13 The property has been ttansfetred to owner above and the unit Received remains in compliance with the requirements of M.G.L.c. 111 22 bate: b BOH• FEB 21 20:0 *THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUB MYfE�I % E ALEM MDPH-CSP SubmeteeriagForm,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.196,§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 an the tenants of a charge for water and/or sewer service. - PROPERTY INFORMATION Address: 205 W ftnd Ave 33fl1 24 Citynown: Salem MA Zi Code:01970 EQUl PMENT 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 fallowing specifications: Showerheads with maximum flow rate not to exceed 2 x Vlons per minute(2.5 gpm) Faucets with maximum flow rate not to exceed 2 2" gallons per minute(2.2 gpm) Ultra-low,flush water closets(toilets)not to exceed 16" galians 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 submeteting equipment Submatming equipment information: Master Meter Flexible Axis Manufactum Model# Licensed Plumber Certificadon Joseph Bellefeuille 9793 12-16-2019 Print Name of Plumber License 0 Date I certify that(check all that apply): IThehave installed the submetering equipment fisted 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 I.6 gallons per flush. plumbing permit issued by the cityAown,if requdsed,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, siamahmm6rucensed Fhnnber 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 subnmetering 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.186,122; (4)The water meter or submeter measures the water ussgc exclusive to this unit;(S)I will pmvide to tic tenants of this dwcftg unik 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 inforawtion included on this certification is true and accurate to the best of my knowledge. Signed under the pains and penalties of perjury, . t�m-,ek QS -+ C&r Vk tz-/(fbol Print Name of Owner Si tore of Owner E D Date The property has been transferred to owner above and the unit Received remains in compliance with the is of M.G.L.c. 186 22 Date: by BOW FEB2Q *THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBMETERING CITY OF SALEM MDPH-CSP Submctering Forth,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.126,§22 and 105 CMR 410.000:Minimum Standards of Fitness for Human Habitation (State Sanitary Code Chapter 11),the following dwelling unit is eligible far the imposition on the tenants of a charge for water and/or sewer service. _ PROPERTY INFORMATION Addrew. 205 Highland Ave 320$ 24 CS crown: Salem MA Zi Code:01970 EQMPMItNT EVSTALLATION 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(arwater and/or sewer.The devices must meet the following specificatiou: Showerheads with maximum now rate not to exceed 216 gallons per minute(2-5 gpm) Faucets with maximum flow rate not to exceed 22W gallons per minute(2.2 gpm) [Thai-low flush water closets(toilets)not to exceed 1 a+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 infomnation: :Master Meter _ Fleuibie Axis .. __ Manufacturer Model# Licensed Plumber Certlflcadon Joseph Bellefeugle 9793 12-16-2019 Print Name of Ptumber Licertse t/ 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 morn 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 cityhown,ifrequired,is attached. ❑Dwelling unit is connected directly to a meter installed by a water company and,in accordance with M.G.L.a 186,§22(p),does not require the installation of a submeter. Signed under the pains and penalties of perjury, Sipature dLicensed Plumber Property Owner Cer'etandoe 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 submetoring law(MGL c.186,§22);(2)All showerheads,faucets,and waux closets in this dwelling unit are water conservation devices that meet the standards specified above;(3)7be 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 char&g 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. Sighed under the pains and penaitics ofpajwy, exec as Print Name of Owner Signature of Owner a D Date The property has been transferred to owner above and the unit Received remains in compliance with the uirements of M.G.L.a 186 §22 Date: by BOH:FEB 21 202 "THIS FORM)MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUIIMETERING CITY OF SALEM MDPH-CSl SubmctobgForm,Rsv 11-4-16 BOARD OF HEALTH MASSACHUSE"ii TS DEPARTMENT OF PUBLIC HFALTH SUBl4IET ERING OF WATER AND SEWER CERTIFICATION FORM *In accordance with M.G.L.c.196,§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: 205 M Maud Ave Unit#3207 9 0irunfic in hift 24 gi iron: Salem MA Zip Code:01970 EQUIPKE:Nf INSTALLATIONINFORMATION 105 CMR 410.000 requires the installation of water conservation devices prior to a dwelling unit becoming eligible far 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 gallons per minute(L2 gpm) Ultra-low flush water closets(toilets)not to exceed t gallons per Hush(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: Master Meter Flexible Axis Manufacturer _ Model# Licensed Plumber Certification Joseph Beilefeulile 9793 12-15-2019 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 flusb. The plumbing permit issued by the city/town,if requited,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 requite the installation of a submetec. Signed under the pains and penalties of perjury, Si shut of Licensed Plumber Property Owner Certification I certiFy that:(1)This dwelling unit is eligible for the imposition on the tenants of n charge for water and/or sewer usage in accordance with the water submetering law(MGL c.186,§22);(2)All showerltcads,faucets,and water closets in this dwelling unit are water conservation devices that meet the standards specified above;(3)The water submater 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.186,4 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 ofwater and/or sower service,and a copy of this certification form;(6)That all information included on [hit certification is true and accurate to the best ofmy knowledge. Signed under the pains and penalties of perjury, 5� ruic- a)H` t e—ltt; Ig Print Name of Owner Sienature of Owner D Date 17 The property has been transfeaed to owner above and tlx:unit Received remains in compliance with the re mirements of M.G.L.c.186 22 Date: b BOH: i _ r "THIS FORM MUST BE FILED WITH THE LOCALBOARD OF HEALTH PRIOR TO INMA'"NG SUBM&EIi N CITY OF SALEPA MDPH-CSP Subrmctering Form,Rev 114-16 BOARD OF HEALTH MASSACFWSETTS DEPARTMENT OF PUBLIC HEALTH SUBMETERING OF WATER AND SEWER CERTIFICATION FORM *In aaconlance with M.G.L.a 1116.§22 and 105 CMR 410.000.Minimum Standards of Fitness for Hurmn Habitation (State Sanitary Code Chapter II),the fallowing dwelling unit is eligible for the imposition at the tenants of a charge for water and/or sewer service - -_ PROPERTY INFORMATION Addnm 205 Highland Ave unit#3206 it nfun;q in h1dor 24 cit-wrown: Salem MA Zip Code:01970 EQUIPKEN'T 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 x p1lons per minute(2.5 Spin) Faucets with maximum flow rate not to exceed 2 ui gallons per minute(22 gpm) Ultra-low flush water closets(toilets)not to exceed t Y10 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 Wodcs Association or similar accredited association. A licensed plumber must install the water closets and submetering equipment. Submetering equipment information: Master Meter Flexible Axis Manufacturer Model# L tensed Plumber Certification �— imph Belleieuille 9793 12-16-2019 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 cityhown.if required,is amched. ❑Dwelling unit is connected directly to a meter installed by a water company and,in accordance with M.G.L.c.186,122(p),does not require the installation of a submcter. Signed under the pains and penalties of perjury, S' cure of Licensed PhuNer 'Property Owner Certification t 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.186,122);(2)Alp showenceads,faucets,and water closets in this dwelling unit ale water conservation devices that meet the standards specified above;(3)The water subineter 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.186.122; (4)The water meter or submeter measures the water usage exclusive to this unit;(S)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 farm;(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, D Print Name of Owner Siatiatum of Owner D Date The property has been transferred to owner above and the unit Received remains in compliance with the mauirements of M.G.L.c.186 422 Date: by BOH: F-F:P 971 170 *THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBMETERING CITY OF SAL_EM MDPH-CSPSubmctuxiog Form,Rm 11.4-16 BOARD OF HEALTH MASSACHUSETFS DEPARTMENT OF PUBLIC HEALTH SUBIVIETERING 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 U),the following dwelling unit is eligible for the imposition on the tenants of a charge for water and/or sewer service. PROPERTY JAMORAIATION Address: 205 W hland Ave Una#3205 24 Ci mwn: Salem MA Zip Code:01970 EQUUWW4T E"TALLATION WFORIKATION 105 CMR 410.000 requires the installation of water conservation devices prior to a dwelling unit becoming eligible for We imposition on tenants of a charge for water and/or sewer.The devices must meet the following specifications: Sbowerheads with maximum flow rate not to exceed 2gallons per minute(2.5 gpm) Faucets with maximum flow rate not to exceed 2 gallons per minute(22 am) Ultra-low flush water closets(toilets)not to exceed 1 611°gallons per flush(1.6 gpf) The submetering equipment used to measure the quantity ofwater used for each dwelling unit and common area must meet the standards of accuracy and testing of the American Water Woft Association or similar accredited association. A licensed plumber must install the water closets and submetering equipment. Submetering equipment information: Master Meter Flexible Axis Manufactu er Model# Licensed Plumber Certifie atlan Joseph Bellefemille 9793 12-16-201 S Print Name of Plumber — Licen e# Date 1 certify that(chock all that apply): 1 have installed the submetcring equipment listed above in accordance with accepted plumbing standards. I have installed one or more water closets not exceeding 1.6 gallons per[lush. Determined that existing water closets do not exceed 1.6 gallons per flush. The plumbing permit issued by the cityltown,if inquired,is attached. ❑Dwelling unit is connected directly to a teeter installed by a water company and,in accordance with M.G.L.c.186,§22(p),does not require the installation ofa submeter. Signed tinder the pains and penalties of pe duay, �' t Swumm of ucense d Phrmber Property Owner Certification I certify that:(1)This dwelling unit is eligible for the imposition on the tettamts of a charge for water and/or sewer usage in accordanc c with the water submetcring law(MGL c.186,§22);(2)Alf showerhesds,faucets,and water closets in this dwelling unit ate 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 im M.G.L.c.186,122; (4)The water meter or subme ter mcasrras the water usage exclusive to this unit;(S)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 bw and accurate to the best of my knowledge:. Signed under the pains and penalties of perjury, Print Name of Owner -% Lure of Owner —4 Gate I3 The property has been transfted to owner above and the unit Received remains in campliance with the requiremmis of M.G.L.c. 186 22 Date: by BOH: FEB 21 20 0 "THIS FORM MUST BE FILED WITH THE LOCAL BOARD Of HEALTH PRIOR TO INITIATING SUBMEfERING CITY OF SALEM MDPH-CSPSubmcW&gForm,Rev I1-4-I6 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 H+rman Habitation (State Sanitary Code Chapter U),the following dwelling unit is eligible fin the imposition on the tenants of a charge for water and/or sewer service. PROPERTY INFORMATION Address: 205 Hi hlaftd Ave 37-04 J9 Of tinlIS in 7nldg.24 Citvfrowz Salem MA Zip Code:01970 EQII'It+ZW DMALLATION INFORMATION 105 CMR 410.000 requires the installation of water conservation devices prier 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%allons per minute(2.5 gpm) Faucets with maximum flow rate not to exceed 2 gallons per minute(2.2 gpm) Ultra-low flush water closets(toilets)not to exceed 16110 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 standard,of accuracy and testing of the American Water Works Association or similaraccredited association. A licensed plumber must install the water closets and submetering equipment. Submetering equipment information: _ Master Meter Flexible Axis Manufacturer model# Licensed Plumber Certification ^ Joseph Bellefeuille 9793 _ 12-16-2019 Print Nance 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 cityltown,if requited,is attached. 0 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. i Signed under the pains and penalties of perjury, S' turc o Licersed Phumber 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.196,§22r(2)All showedm ads,faucets,and water closets in this dwelling unit ate water conservation devices that meet the standards specified above:(3)The water submcter 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.196,122, (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, (�l16 Print Name of Owner Signature of Owner Date Tbc property bias been transfccred to owner above and the unit Received FEB 21 20 0 remains in con tiance with the uirements of M.G.L.c. 186 22 Date: b Bog: °THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBIV V Rr©F S/ 1. . .i MDPH-CSPSubmete&gForm,Rev 11-4-16 BOARD OF HEr,LFFI MASSACHUSETTS DEPARTNIENT OF PUBLIC HEALTH SUBMETERING OF WATER AND SEWER CERTNICATION FORM *In accordance with M.G.L.c.1116,§22 and 105 CMR 410.000.Minimum Standards of Fitness for Human Habitation (State Sanitary Code Chapter II),the hollowing dwelling unit is eligible for the imposition on the tenants of a charge for water andlor sewer service. PROPERTY INFORMATION --— Adclms: 205 Highland Ave Linit#3203------,u 24 Ci Rbwn: Salem MA 2i Code:01970 EQUIPMZi:N'I'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: Sbowerheads with maximums flow rate not to exceed 2:01ons per minute(2.5 gpm) Faucets with maximum flow rate not to exceed 2 gallons per minute(22 gpm) [Iltro-low flush water closets(toilets)not to exceed I d1e 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 Worts Association or similar accredited association. A Iicensed plumber must install the water closets and submeteting equipment Submetering equipment information: Master Meter Flexible Axle Manufacturer Model# I.feensed Phunher Certf-tlentton _ _Joseph Bellefe_ullle _ 9793 12-16-2019 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 gations per flush. Determined that existing water closets do not exceed 1.6 gallons per flush. Ile plumbing permit issued by the cityAown,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 subtatter. Signed under the pains and penalties of perjury, ' ` " ` Simaftim bfLicosed Plumber -- — Property Owner Certification 1 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 submsteft law(MGL c.186,§22);(2)All showcrbeads,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 gloater company" as defined in M.G.L.c.186,§22; (4)The water meter or submeter measures the water usage exclusive to dds unit;(5)I will provide to the tenants of this dwelling unit,prior to occupancy,a written rental agreement that clearly provides rar the separate charging orwater and/or sewer service,and a copy of this certification form;(6)That all information included on this certification is true and accurate to the best of my knowledge. Signed under the pains and penalties of perjury, J c>r�x d kQs i• Ivy--- ( l Print Name of Owner Signature of Owner Date The property has been transferred to owner above and the unit Received FEB 21 202 remains in compliance with the manke rents of M.G.L.c. 186 22 Date: b BOH: 'THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING 548 I YMALEM M0PH-CSPSabmcteringSorm,Rcv 11-0-16 BOARD OF HEALTH MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH SUBMETERINO OF WATER AND SEWER CERTIFICATION FORM "In accordance with M.G.L.c.186,122 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: 205 Hi hiand Ave unit tP3202 r. hmp 24 City/Town: Salem MA zip Code:01970 EQu PmzNT 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 ofa charge for water and/or sewer.The devices must meet the fbiiowing specifications: Showetheads with maximum flow rate not to exceed 2 agallons per minute(2.5 gpm) Faucets with maximum flow rate not to exceed 2 gallons per minute(2.2 gpm) Ultra-low flush Water closets(toilets)not to exceed 1 gallons per flush(1.6 gpf) The submetering equipment used to measure the quantity of water used for each dwelling unit and common area mast 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: Master Meter Flexible Axis Manuflieft er Model# Licensed Plumber Certification Joseph Bellefet.tille 9793 12-16-2019 Print Name of Plumber - License# -- _ Date FDetemined (check all that apply): alled the submetering equipment listed above in accordance with accepted plumbing standards. talled one or more water closets not exceeding 1.6 gallons per!lush. that existing water closets do not exceed 1.6 gallons per flush.pbing 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. 196,§22(p),does not require the installation ofa submeter. Signed under the pWw and penalties of perjury, h zasmat=ht Licensed Phdhbcr Property Owner Certification 1 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 submctering law(MGL c.186,§22),(2)All sbowedumds,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 farm;(6)That all infortnation included on this certification is true and accurate to the best of my knowledge. I ed under the pains and penalties ofpcdwy, r Q>- 6� 0. Print Name of Owner Si=ature of owner H1 ' Date O The properly has been transferred to owner above and the unit Received remains in compliance with the n Anhements of M.G.L,c 186 22 Date: by BOH:FEB 21 202 'THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBMETERING CITY OF SALEM MDPH-CSPSubmctabg Form,Rcv 11 4-16 BOARD OF HEALTH MASSACI3USETTS DEPARTMENT OF PUBLIC HEALTH SU$NIETERING OF WATER AND SEWER CER'I'MCATION FORM *In accordance with M.G.L.c.186,§22 and 105 CMR 410.000:Minimum Standards of Fdaess for Humus Habitation (State Sanitary Code Chapter II),the following dwelling unit is eligible for the imposition an the tenants of a charge for water andkr sewer service. PROPERTY INFORMATION Address: 205 W hland Ave Link t401 24 Ci /Town: Salem MA Zip Code:01970 EQUItP'MTM INSTALLATION INFORMATION 105 CMR 410.000 requires the installation of water conservation devices prior to a dwelling unit becoming eligible for the imposition an tenants of a charge for water and/or sewer.The devices must meet the following specifications: Sbowetheads with maximum flow rate not to exceed 2 x gallons per minute(2.5 gpm) . Faucets with maximum flow rate not to exceed 2 m gallons per minute(2.2 gpm) Ultra-low flush water closet(toilets)not to exceed 1 6't0 gallons per flush(1.6 gpl) 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 trust install the water closets and submetering equipment Submetering equipment information: Master deter Flexible Axis Manufacturer Model# Licensed Plumber Certi icatlon Joseph l3elleteuille 9793 12-16-2019 Print Name of Plumber License# Date I certify that(chicle all that apply): 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 cityAown,if required,is attached Q Dwelling unit is connected directly to a meter installed by a water company and,in accordance with M.G.L.e.186,§22(p),dots not require the installation of a submeter. Signed under the pains and penalties of perjury, _ Stirnaturg of Licensed bee - - _- Property Owner Certiscation 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 submatcring law-(MGL c.186,.§22);(2)All showcnccads,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 farm;(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 7be property leas been transfetsed to owner above and the unit Received remains in cornpliance with the requirements of M.G.L.c. 186,122 Date: by BOH: FEB 21 2 20 "THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING'UB�MVSALEM MDPH-CSP Submetering Form,Rev 11.4-16 BOARD OF HEALTH MASSACIHUSET!'S 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 Frtness for Human Habitation (State Sanitary Code Chapter U),the following dwelling unit is eligible for the imposition on the tenants of a charge for water and/or sewer_mvice- PROPERTY INFORMATION Address: 205 Highland Ave .--3108 of units in hm, 24 ' frown: Salem MA Zi Code•01970 EQUIPl1Ma INSTALLATION DWORMATI<ON 105 CMR 410.000 requims the installation of water conservation devices prior to a dwelling unit becoming eligible far the imposition ou tenants ofa charge for water and/or sewer.The devices must meet the fallowing speciScations: Showerheads with maximum flow rate not to exceed 2 lIons per minute(L5 gpm) Faucets with maximum flow rate not to exceed 2 gaiians per minute(2.2 gpm} U3tra-low flush water closets(toilets)not toexceed i s"Q gallons per flush(1.6 gpt) 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 similarac credited association. A licensed plumber must install the water closets and submetering equipment Submetering equipment information: Master Meter Flexible Axis Manufacturer Model 4 Licensed Plumber Certification Jesseph Bellefouille 9793 12-16-2019 Print Name of Plumber License 0 Date I certify that(check all that apply): 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 cityhown,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 Si tore drUcensed ftwAa 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.186.122).(2)All showenccads,faucets,and water closets in this dwelling unit am water conservation devices that meet the standards specified above;(3)The water submeter measuring the use of water in the dwelling trait 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.186,122; (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 dearly provides for the separate charging of water and/or sewer service,and a copy of this certification Form;(6)Iliac all information included on this certification is true and accurate to the best of my lmowlcdge. Signed under the pains and penalties of perjuty, Q5C r q-s t. 6-,, 4- tom-• l2 lf6 / , Print Name of Cwncr Silmature ofowner Date 9bc property has been transferred to owner above and the unit Received remains in Modiance with the rNuftanents of M.G.L.c. 186 22 Date: hy Bo1FEB 2.12020 *THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBMETERING CITY OF SALEiVI MDPH-CSPSubmcteciag Form,Rcv I1.4-16 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 111 the fallowing dwelling unit is eligible for the imposition on the tenants of a charge far water and/orsawer service. PROPERTY INFORMATION Address; 205 Highland Ave Unit 93107 24 City/Town: Salem MA Zie Code:01970 EQUMM 14T 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 ofa charge for water and/or sewer.The devices must meet the following specifications: Showetheads with maximum flow rate not to exceed 2%;Vlons per minute(L5 gpm) Faucets with maximum flow rate not to exceed 2 gallons per minute(2.2 gpm) Ultra-low flush water closets(toilets)not to exceed 1 s`10 gallons per flush(1.6 gp0 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 wodcs Association or similar accredited association. A licensed plumber must install the water closets and submotering equipment. Submetering equipment infestation: Master Meter Flexible Axis Manufacturer Model# Licensed Plumber Certiflcatioa Joseph Bellefeuille 9793 12-16-2019 Print Name of Plumber License# Date I cerdFy that(check all that apply): I have installed the submeterft equipment listed above in accordance with accepted plumbing standard. 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 cityhown,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 ofa submeter. Signed under the pains and penalties of pedtuy, A t!� S' ature of Licensed Ph r Property Owner Cerdocaden 1 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.186,1221-(2)All showeahrads,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 unik prior to occupancy,a written rental agreement that clearly provides for the separate charging orwater and/or sewer service,and a copy of this certification faun;(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 pejuty, K aS A,,-err I vWes--- 2 n Print Name of Owner Sienaturc of Owner D LbBOH. te The property has been transferred to owner above and the unit ceived FEB 2 1 ZO remains in fiance with the ahcments of M.G.L.c.186 22 Date: 'THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SU FR%ALEM MDPH-CSPSubnectering.Form,Rew 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.196.§22 and 105 CMR 410.000.Minimum Standards of Fitness for Human Habitation (State Sanitary Code Chapter M the following dwelling unit is eligible for the imposition on the tenants of a charge for water and/or sewer service. PROPERTY INFORMATION Address: 205 Highland Ave Urlit if3106 a jof mim i,hwc 24 City/Town: Salem MA Zip Code:01970 EQUVNMNT 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 ancUor sewer.The devices must meet the following specifications: Showaheads with maximum flow rate not to exceed 2"gallons per minute(2.5 gpm) Faucets with maximum flow ratan not to exceed 2 gallons per minute(2.2 gpm) Ultra-low flush water closets(toilets)not to exceed 1 firma gallons per Busb(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 simiiarac credited association. A licensed plumber must install the water closets and submetering equipment. Submetering equipment information: pilaster Meter Flexible Axis Manufacturer Model 0 Licensed Plumber Certification Joseph Belieteuille 9793 12-16-2019 Print Name of Plumber � License# y 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 are 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, _ e n v Si tune of Licansaki Plumber Property Owner Certification t cerdfy 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 subm atering law(MGL c.186,§22);(2)All showencaads,faucets,and water closets in this dwelling tacit ate 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 fort ;(6)That all information included on this certification is false and accurate to the best of my knowledge. Signed under the pains and penalties of perjury,zS L &..u— U, (*' t6 l Print Name of Owner Signature ofowner HIDGE Date C3 The properly has been bmfkn ed to owner above and the unit Received remains in compliance with the requirements of M.G.L c.186 §22 Date: by BOH: FEB 2120 0 *THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBMETERING CITY OF SALEM MDPH-CSP Subnwkriag Fenn,Pzv 11 4-16 BOARD OF HEALTH MASSACRUSETTS DEPARTMENT OF P1.78LIC HEALTH SUBMETERING OF WATER AND SEWER CERTIFICATION FORM *In accordance with M.G.L.a 186,§22 and 105 CMR 410.GW:Minimum Standards of Fitness forHu man 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: 205 Highland Ave i ini,0105 24 Q rI'own: Salem MA ;j Code:01970 EQUIPMENT INSTALLATION INFORMATION 105 CMR 410.000.requines 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'tallons per minute(L5 gpm) Faucets with maximum flow rate not to exceed 2 gallons per minute(7-2 gpm) Uhm-low flush water closets(toilets)not to exceed 1 ei0 gallons per flush(1.6 gpQ The submelering 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 Wodcs Association or simi'iaraceredited association. A licensed plumber must install the water closets and submetaiag equipment Submetering equipment information: Master Meter Flexible Axis Manufacturer Model# Ideessed Plumber Certification Joseph Bellefeuiile 9793 12-16-2019 Print Name of Plumber License# Bate 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 cityhown,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, d i aLpmurre orticensed Pham Property Owner Certification I certify that:(1)'Mis dwelling unit is eligible for the imposition on the tenants of charge for water and/or sewer usage is accordance with the water submatering law(MGL c. 186,§22);(2)All showerheads,faucets,and water closets in this dwelling unit are water conservation dtwices 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.186,1 22; (4)The water meter or submeter measures the water usage exclusive to this unit;(S)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 fbrrn;(6)That all information included on this certification is tux and accurate to the best of my knowledge. Signed under the pains and penalties of perjury, 2—/l(./( Print Name of Owner Si afore of Owner D Date Cl The property has been trawf red to owner above and the unit Received remains in cowliance with the nMirernents of M.G.I..c.186,422 hate: by BOH: EER 2 1 2G 0 *THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBMETERING CITY OF SALEM MDPH-CSPSubmaetering Form,Rev 114-16 BOARD OF HEALTH MASSACEWSETTS DEPARTNIENT OF PUBLIC HEALTH SIBNIETERING OF WATER AND SEWER CERTIFICATION FORM *In accordance with M.G.C..a 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: 205 Highland Ave UnLl 03104 #inf tinift in h1djC 24 Ci !Town: Salem MA Zt Code:01970 EQUMMENT INSTALLATION INFORMATION 105 CMR 410.000 requires the installation of water conservation devices prier'to a dwelling unit becoming eligible for the imposition on tenants of a charge fbr water and/or sewer.The devices must meet the fallowing specifications: Showaheads with maximum flow rate not to exceed 2 Mons per minute(2.5 gpm) Faucets with maximum flow rate not to exceed 2 gallons per minute(22 gpm) Ultra-low flush water closets(toilets)not to exceed t dk°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 ofthe American waterworks Association or similar accredited association. A licensed phmdw must install the water closets and submetering equipment. Submetering equipment information: Master meter Flexible Axis Manufscturer Model - Licensed Plumber Certification Joseph Sellefeuille 9793 12-16 2019_ Print Name of Plumber - -- - License# Date z certify that(check all that apply): have installed the submetering equipment listed above in accordance with accepted plumbing standards. 1 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 cityAown,if required,is attached. ©Dwelling unit is connected diriectly 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. 04 Signed under the pains and penalties of perjury, 1-e --"F rrTT Si store olVicensed Purring 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 showenccads,faucets,and water closets in this dwelling unit are water conservation devices that meet the standards specified above;(3)7be 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'%vate:r company" as defined in M.G.L.c.186,§22; (4)The water meter or submeter measures the water usage exclusive to this unit;(S)t 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, On-,Laa A,,+ U Print Name of Owner Sufiature of Owner R unite- D Date E3 Tbc property has been transferred to owner above and the unit Received retnsins in camp liance with the requirements of M.G.L.r- 186 22 Date: by BOH: FEB 21 20 *THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SLIBMETERING CITY OF SALEM MDPH-CSPSubmctcdngFarm,Rev t1-4-16 BOARD OF HEALTH ��� - I i I � I � ■r � I 1 •_ - I - MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH SUBM,TERING OF WATER AND SEWER CERTIFICATION FORM *In acconlance with M.G.L.c.196,§22 and 105 CMR410.000:Mininman Standstds of Fitness for Human Habitation (Slate Sanitary Code Chapter ED,the following dwelling unit is eligible for the imposition on the tenants of a charge for water and/orseweer service. _ PROPERTY INFORMATION T Address: 205 Highland Ave Unit hL3103 90funiftinbldy 24 Ci R'own: Salem MA i~i Code:01970 EQUVMENT INSTALLATION INFORMATION 105 CMR 410.000 requites 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: Sbowerheads with maximum flow rate not to exceed 2 ons per minute(2.5 pm) Faucets with maximum flow rate not to exceed 2 gallons per minute(2.2 gpm) Ultra-low flush water closets(toilets)not to exceed I &1°gallons per Gush(1.6 gpf) Tbc submetering equipment used to measure the quantity ofwater 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 submeteting equipment. Submeteriug equipment information: Master Meter _ Flexible Axis Manufacturer Model# Licensed Plumber Certification 1 Jo3eph Bellefeuille 9793 12-16 2019 Print Name of Plumber License# Date I certify that(chcdt all that apply): 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 cityhown,if required,is attached ❑Dwelling unit is connected directly to a meter installed by a water company and,in accordance with M.G.I..c-196,$22(p),does not require the installation of a submeter. Signed under the pains and penalties of perjury. Si a ofLicens �PZber - - Property Owner CertlAentlon I certify that:(1)This dwelling unit is eligible for the imposition on the tenants of a charge far water and/or sewer usage in accordance with the water submtate ft 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 writ 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 foray;(6)That all information included on this certification is acre and accurate to the best of my knowledge. Signed under the pains and penalties of perjury, r n—L9 Ors— c� Print Name of Owner Signature of Owner D Date Tbc property has been transferred to owner above and the unit Received remains in compliance a with the twuirements of KG-L,c. 186 22 Date: by BOH: FEB 21 20 0 *THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIAl1NG SUBMETERING CITY OF SALEM MDPH-CSPSubraeteting Form,Rev I1.4-16 BOARD OF HEALTH MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH SUBMETERING OF WATER AND SEWER CERTIFICATION FORM *In accmdaace with M.G.L.c.l 86,§22 and 105 CMR 410.000:Minimum Standards of Fitness for Human Habitation (State Sanitary Code Chapter E%the following dwelling unit is eligible for the imposition on the tenants of a charge for water and/orsewer setrvice. PROPERTY INFORMATION Address: 205 H hland Ave 102 24 g!y/Town: Salem MA Zip Code:01970 EQUEPMMNT EMALLATION INFORMATION 105 CMR 410.000 requires the installation of water conservation devises 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 24 gallons per minute(2.5 gpm) Faucets with maximum flow rate not to exceed 2 gallons per minute(L2 gpm) Ultra-low flush water closets(toilets)not to exceed 1,910 gallons per flush(1.6 gpf) The submetering equipment used to f11easu+re 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 similes accredited association. A licensed plumber must install tie water closets and submetering equipment. Submetwing equipment information: Master Meter Flexible Axis Manufacturer Model# Licensed Plumber Certification Joseph Bellefeuille 9795 12-16-2019 Print Name of Plumber License# Date I cexti fy 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 cityhown,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, SiumauiY of Licensed Muniber Property Owner Cerdlirntion 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 submetcriag law(MGL c.186,§22);(2)All showerheads,faucets,and water closets in this dwelling unit ate water conservation devices that meet the standards specified above;(3)'I'lhe 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.186,1 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 f ran;(6)That all information included on this certification is true and accurate to the best of my knowledge. Signed under the pains and penalties ofpcd Q / Print Name of Owtier Si 6we_of owner E D Date 17'The property has been transfrrred to owner above and the unit Received d rehhhains in compliance with the requirements of M.G.L.c. 186 22 Date: by BOH: FEB 2 12090 "THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBMEIERtNG CITY OF SALEM MDPH-CSP Submetedng 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 CMR410.000:Minimum Standards of Fitness for Human Habitation (State Sanitary Code Chapter II),the fallowing dwelling unit is eligible for the imposition an the tenants of a charge for water anaior sewer service. PROPERTY INFORMATION Address: 206 Highland Ave __UajL 101 24 Ci : n: Salem MA Z' Code:01970 E !UIPb W INSTALLATION INFORMATION 105 CMR 410.000 requires the installation of water conservation devices prior to a dwelling unit becoming eligible for the imposition an tenants of a chap for water and/or sewer.The devices must meet the failowmg specifications: Showerheads with maximum flow rate not to exceed 2 x gallons per minute(L5 gpm) Faucets with maximum flow rate not to exceed 2 m gallons per minute(22 gpm) f Ultra-low flush water closets(toilets)not to exceed 1'°pitons per flush(l.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 infomtation: Master'Meter Flexible Axis Manufacturer Model# licensed Phtmber Certification f Jmph Bellefeuille 9793 12-16-2019 Print Name of Plumber License# Date I certify that(check all that apply): MI have installed the submetering equipment listed above in accordance with accepted plumbing standards. I have installed one or mote water closets not exceeding 1.6 gallons per Bush. 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.e.186,1 22(p),does not require the installation of submeter. Signed under the pains and penalties of perjury, IV Sittnaturc�dLirensed Plumber - — Property Owner CettiBeadon ~ �� l 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 subtnetering 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,of 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.186,122-, (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 forms;(6)That all information included on this certification is true and accurate to the best of my knowledge Signed under the pains and penalties ofpmjury, 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 muiraments of M.G.L.c.186 22 Date: by BOH:FEB 21 202 "'THIS FORM MUST BE FILED 1Al TH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING Sl1 Y Oi`SALEM MDPH-CSPSubmeteft Form,Rev 114-16 BO�+'AIRD OF HEALTH