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Water submeter certificates - Units in the 4s 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 Smalley code Chapter to,the following dwelling unit is eligible for the imposition an the tenants of a charge for waterand/orsew--service. PROPERTY INFORMATION Address; 205 Hi hiand Ave ignhift,24 city/Town: Salem MA Zip Code:01970 EQUIPII+I$NT INSTALLATION IlYFORMATION 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 fallowing specification; Showedmds with maximum flow rate not to exceed 2:Ilons per minute(2.S gpm) Faucets with maximum flow rate not to exceed 2 gallons per minute(2 2 Rpm) � Ultra-low flush water closets(toilets)not to exceed 1 a�14 gallons per flush(1.6 gpt) The submetering equipment used to measure the quantity of water used for each dwelling unit and common area muse 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 Certfflcatfon —Jose—ph 0etieieuille_ _ $793 12-16 2019 Print Name of Plumber License# Date I certify that(check all that apply): I have installed the submetetiag 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 required,is attached Q Dwelling emit 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 of a submwer. Signed under the pains and penalties of perjury, I E Si lure f Licerind er Property Owner CerNScation I cerdtly that(1)This dwelling unit is eligible for the imposition on the tenants of a charge for water mWor sewer usage in accordance with the water submetering law(MGL c.186,122);(2)All showedumds,faucets,and WNW 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 in M.G.L.c. 1116,§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 infomuation included on this certification is ttuc and accurate to the best of my knawledgc. Signed under the pains and penalties of perjury, Print Name or Owner Sicnature of0woer E D Date Q The property has been transfermd to owner above and the unit Received FEB 2-1 2 0 remains in con Apliance with the requirements of M.G.L.c. 186 22 Date: by BOH: i°THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIORTO INITIATING SU$ WSALEM BOARD OF HEALTH t►4DPH-CSP tiubrrrcteciag Form,lieu It-4-16 MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH SUBIVIETERING OF WATER AND SEWER CERTIFICATION FORM *In accordance with M.G.L.c.1116,§22 and 105 CMR 410.000:Minimum Standards of Fitness far Human Habitation (State Sanitary Code Chapter I1),the fallowing 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 :307 24 Ci /Town: Salem MA Pp Code:01970 EQUIPMENT IiNS'TALLA ION INFORMATION 105 CMR 410.000 requires the installation of water conservation devices prior to a dwelling unit becoming eligible for the imposition on tenants ofe charge farwater and/orsewer.The devices must meet the fallowing specifications: Sbowedwads with maximum flow rate not to exceed 2:jallons per minute(2.5 gpm) Faucets with maximum flow rate not to exceed 2 gallons per minute(2.2 gpm) Ultra-tow flush water closets(toilets)not to exceed 1610 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 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# J Cleared Plundmr CertUlcation - Jt>seph Bellefeullle 9793 12-1 S 2019 Print Name ofPhimber 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 cityRawn,if required,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 of a submeter. Signed under the pains and penalties of perjury, --_ IVS' ature of Licensed himber Property Owner Certlflcadon 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 submetering law(MGL c. 186,§22);(2)All sbowedicads,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 ab=4 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 certi fication form;(6)That all information included on this certification is true and accurate to the best of my knowledgm Signed under the pains and penalties of perjury, oA d,+ 64w- ' 042 l /c- Print Name of Owner Si attrre of Owner D Date 0 Ile property has been transferred to owner above and the unit Received remains in compliance with the reggiremerits of M.G.L.r; 18 22 Date: by BOH:FEB 21 202 nHIS FORM MUST BE FILED V41TH THE LOCAL BOARD OF HEALTH PRIOR TO INMA nNG SUBMETERING CITY OF SALEM MDPH-CSP Submetering!"orm,Rev 114-16 BOARD OF HEALTH MASSACQUSEITS DEPARTMENT OF PUBLIC HEALTH SUBN=RING 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 In,the&&lowing dwelling unit is eligible far the imposition an the tenants of a charge for water anftrwwer service. PROPERTY INMRKATION Address: 205 Hi hlattd Ave- 306 0 DLnmtS in bjdL24 city/Town: Salem MA Zi Coda:01970 EQUIPBM4T 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 fbr water and/or sewer.The devices must meet the Wowing specifications: Showed=&with maximum flow rate not to exceed 2:01ons per minute(2.5 gpm) Faucets with maximum flow rate not to exceed 2 galIons per minute(2.2 gpm) Ultra-low flush water closets(toilets)not to exceed 16"9 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 Works Association or similaraecredited association. A licensed plumber must WWI the water closets and submetering equipment Submetering equipment infomsadon: Master Metes' Flexible Axis. Manufacturer Model# Licensed Plumber Cerdflcadon 301!eph Belletouille 97_93_ 12-16-2019 Print Name of Plumber -- License# i Date I certlty that(check all that apply): I have installed the snbmetering equipment listed above in accordance with accepted plumbing standards. I have installed one or more water closets not exceeding 1.6 gallons per Bush. Detttmined 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 trait is connected directly to a meter installed by a water company and,in accordance with XG.L.c.186,§22(p),does not inquire the installation of a submeter. Signed under the pains and penalties of perjury, h v Sianeture of Licensed Plumber Property Owner Cerffimtian I certify that:(1)This dwelling unit is eligible for the imposition on the tewmts of a charge for water and/or sewer usage in accordance with the water submetering law(MGL c.186,§22);(2)AD showerheads,fauccts,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 foray(6)That all information included on this certification is t m and accurate to the best of my knowledge. Signed under the pains and penalties of peduty, t �a3Ajj1" e Print Name of Owner Simabm of Owner Date E3 The property has been traos&nvd to owner above and the unit Received FEB 2 1 202 retnafas in con /lance with the uiremenis of M.G.L.a 186 22 Date: b BOH: *THIS FORM MUST BE FLIED WRH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SU8WITMALEM MDPH-CSP SubracteringForm,Rev 11.4-16 BOARD OF HEALTH MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH SUBMV,TERING OF WATER AND SEWER CERTIFICATION FORM *10 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 an the tenants of a charge for water and/or sewer service. PROPERTY IiNFORIKATION Address: 205 H hland Ave 305 #of 24 Ci gown: S81etn MA Zi Code:01970 EQUIPbW4T INSTALLATION INFORbtATION 105 CMR 410.000 equines the installation of water conservation devices prior to a dwelling unit becoming eligible for the imposition on tenants of it 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(22 gpm) Ultra-low flush water closets(toilets)not to exceed 1 8'0 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. Ali sed plumber must install the water closets and submeteting equipment. Submeetcring equipment information: Master Meter Flexible Axis ManufactulR Model# Licensed Plumber Cerdfieation Jamph Bellefoullle _ 9793 12-16-2019 Print Name of Plumber License# Date I certify that(cbeck 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. Detecmiaed that existing water closets do not exceed 1.6 gallons per flush. The plumbing permit issued by the city/town,if required,is attached Q Dwelling unit is connected directly to a meter installed by a water company and,in accordance with M.G.I..c.186,§22(p),does not require the installation of a submeter. Signed under the pains and penalties of perjury, n -- _ —:— Sinature (Licensed Phi6iber Properly Owner Certifleatfon t certify that:(1)This dwelling unit is eligible ror the imposition on the tenants of a charge for water and/or sewer usage in accordance:with the water submetering law(MGL e. 196,§22);(2)AD showerheads,faucets,and water closets in this dwelling unit are water conservation devices that meet the standards specified above;(3)Ilia 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)11c 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 ror 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. M Signed under the pains and penalties of perjury, �.� lrl-�- C-5 -cl 6-t, r D Print Name of Owner Si>anatura of Owner Date The property has been transferred to owner above and the unit Received FEB 2 12010 remains in compliance liance with the requirements of M.G.L.c- 186, _ Date: b BOH: OTHIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING Sll I T lilMALEM MDPH-CS?Submatering Form.Rev 114-16 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 timents of a charge for water and/or sewer service. PROPERTY INFORIYIATION Address: 206 Highland Ave typir#4304 #Ofunift Y4 Citvrrown: Salem MA Zip Cade:01970 EQUI PhM4T INSTALLATION INFORMA77ON 105 CMR 410.000 requires the installation of water conservation devices prim to a dwelling unit becoming eligible for the imposition an tenants ofa charge for water and/or sewer.The devices must meet the following specifications: Showetheads with maximum flow rate not to exceed 2�Ilons per minute(2.5 gpm) Faucets with maximum flow rate not to exceed 2 gallons per minute(22 gpm) Ultra-tow,flush water closets(toilets)not to exceed 1&ro 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 acctuaey and testing of the American Water Wotks Association or similaraccredited association. A licensed plumber must install the water closets and submetering equipment. Submetering equipment information: Mastw Rueter Fle)dble Axis Manufacturer Model# Licensed Plumber Certification Joseph Bellefeuilie 9793 12-16-2019 Print Name of Plumber License# 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 city/town,if required,is attached. ❑Dwelling unit is connected directly to a ureter 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 pair and penalties of perjury, ' o. Si ature ofLicensed 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 subrretering 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;(S)I will pmvkle 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, to JL� � � � •t_ `� 2 ltb f Print Name of Owner Si afore of Owner Date ❑The property has been transferred to owner shove and the unit Receiv ranains in liance with the requirements of M.G.L.c, 186 22 Date: b Boni'Es 2 12020 *THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBMETERING CITY OF zAL._M MDPH-CSPSubmcteringForm,Rev 11.4-16 BOARD OF H1::AL.1-14 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 far Human Habitation (State Sanitary Code Chapter H),the following dwelling unit is eligible for the imposition as the tenants of a charge for water and/or sewer service. . PROPERTY INFORMATT011t Address: 205 Hi hlandAve _ _ at,�,4303 f1flinift in hid& 24 Ci !Town: Salem MA Zip Code:01970 EQUIPMENT INSTALLAMION DWORMATION 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: Sbowetheads with maximum flow rate not to exceed 2 x4gallons 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 t 6'10 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 tweet the standards of accuracy and testing of the American Water Works Association or similar accredited association. A licensed plumbw must install the water closets and submetering equipment. Submetering equipment information: Master Meter Flexible Axis Manufacturer Model 0 Licenud Plumber CertUication Joseph Bellefeu5le 9793 _ 12-16-2019 Print Name of Plumber License# Date- — 1certify 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,ifrequired,is attached. ❑Dwelling unit is connected directly to a meter installed by a water company and,in accordance with M G.L.e. 186,122(p),does not require the installation of a submeter. Signed under the pains and penalties of perjury, t 'censer P16nber Property Owner Certification I certify that:(1)This dwelling unit is eligible for the imposition on the tenants of a charge fcr 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 swulsrds 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 mcasures the water usage exclusive to this unit;(5)[ will providt 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 an this certification is true and accurate to the best of my knowledge. Signed under the pains and penalties of perjury, Print Name of Owner Date Signature of Owner - a — D O The property has been transfeaed to owner above and the unit Received remains in compliance with the requirements of M.G.L.c. 186 22 Date: b BOH:FEB 21 202 *THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBMETERING CITY OF SALEM MDPH-CSPSubmcteringForm,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 IT),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 02 24 Ci fTown: SaIGM MA Zip Code:01970 EQUIP'MRNT 9gSTALLATlON DwORMATION 105 CMI;410.000 requires the installation of water conservation devices prior to a dwelling unit becoming eligible for the imposition on tenants of a charge forwater and/or sewer.The devices must meet the following specifications: Showerheads with maximum flow rate not to exceed 2 x"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 1*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 standard,of accuracy and testing of the American Water Works Association or similaraeaedited association. A licensed plumber must install the water closets and submetering equipment. Submetering equipment information: Master Meter Flexible Axis Manufactur r Model 0 Licensed Plumber Certification Jweph Bellefeuille 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 cityltown,if requited,is attached. ❑Dwelling taut 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 pedtry, f' Simature of Licensed Phmdkr Property Owner eertflication 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 subrncta*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 complianac 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 defamed 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 I this certification is true and accurate to the best of my knowledge. Signed under the pains and penalties ofpe Bury, 2l 6/t'� Print Name of Owner Sianature of Owner Date °7ttc property has been tratuferred m owner above and the unitei"` EB 212020 ranains in compliance with the requirements of M.G.L.a 186 _22 Date. b BGH. *THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING tu TOLEM 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 D),the following dwelling unit is eligible for the imposition on the tenants of a charge for water and/or sewer services PROPERTY INFORMATION Address: 205 Highland Ave 301 24 • !Town: Salem MA ZI Code:01970 EQUMIKE"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 chap fvr water and/or sewer.The devices must meet the following specifications: Sbowerheads With maximum flow rate not to exceed 2 aiIons per minute(2.5 gpm) Faucets with maximum flow rate not to exceed 2 gallons per minute(2.2 am)Ultra Ultra-low flush water closets(toilets)not to exceed 1 tiro 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. Subm eteriag equipment information: Master Meter Flexible Axis - M-1facturer Model 0 Licensed Plumber Certiflcatlon Hellefeuille 9793 12-16-2019 Print Name of—Ft rmber License# Date Im I certify that(check all that apply): I 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 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, Ict &Moo V S' ture�f Licensed Plumber 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 subtuctcring law(MGL c.186.§22),(2)All showenceads,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"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 form;(6)That all information included on this certification is true and accurate to the best ofmy knowledgc. Signed under the pains and penalties of pcjty,eti Print Name of Owner SiSratute of Owner The property has been transfeseed to owner above and the unit "'°�FEB 21 202 remains is Iiance with the uirements of M.G.L.a l86 Z2 Dnte: [b�BOH : *THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING Sl 1PIFF-MLEM MDPH-CSP Submetuing Form,Rev 11.4-16 BOARD OF HEALTH MASSACHDSETTS 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 U),the following dwelling unit is eligible for the imposition on the tenants of n charge for water and/or sewer service. PROPERTY INFORMATION Address: 205 H hlartd Ave 20$ At 13f 24 gown: Salem MA Zip Code:01970 EQUEMMNT INSTALLATION E41 ORMAITOPI 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 specific&'toms: Sbowerheads with maximum flow rate not to exceed 2%gallons per minute(2.5 gpm) Faucets with maximum flow rate not to exceed 2 m gallons per minute{22 gpm) Uhra-taw flush water closets(toilets)not to exceed I s"0 gallons per flush(1.6 gpQ 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 Wodm Association or similar accredited association. A lioeased plumber must install the water closets and submeteting equipment. Submetering equipment in&rmation: Master Meter Flexible Axis manufacturer _ Model# Licensed Plumber Certff!rp tlon Joseph Belleteullle 9793 12-15-2019 Print Natrts of Plumber — License# Date I certify that(check all that apply): PI 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 city/town,if required,is attached. ❑Dwelling trait is connected directly to a meter installed by a water company and,in accordance with M.G.I..a 186,§22(p),does not require the installation of a submeter. Signed under The palm and penalties of perjury, Si tuts of itxnsed P r 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 subtaetering law(MOL c. 186,§22);(2)All showedmct,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 agr&ement that clearly provides for the: separate charging of water and/or sewer service,and a ropy of this certification forte;(6)That all information included on this certification is tree and accurate to the best of my knowledge. Signed under the pains and penalties ofpajury, S-k Print Name of Owner 17 Si atone of Owner n Date The property has been transferred to owner above ancll!86 omit Received FEB 21 202 remains in compliance with the uirements of M.G.L, 22 Date: b BOH: 'THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SFLEM MDPH-CSPSubmeitring 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.196,122 and 105 CMR 410.000:Minimum Standards of Fitness for Human Habitation (State Sanitary Code Chapter ED,the fallowing dwelling unit is eligible for the imposition an the tenants of a charge for nodvur sewer sseervice. � - PROPERTY WFORLt+1ATION Address. 205 Highland Ave 207 24 G it own: Salem MA Zi Code•01970 EQUWbWLNT INSTALLATION WFORMATION 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 U%lons per minute(2.5 gpm) Faucets with maximum flow rate not to exceed 2 gallons per minute(22 gpm) Ultra-low flush water clot(toilets)not to exceed I d10 gallons per Cush(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 Watks Association or similar accredited association. A licensed plumber must install the water closets and submetering equipment. Submetering equipment information: Master Meter Flexible Axis Manufacturer Madel6 Licensed Plumber CertMeation Joseph Beilefeuille 9793 12-16-2019 Print Name of Plumber License 0 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. 186.1 22(p),does not require the installation of a submeter. Signed under the ga pains and penalties of perjury, Si ofLieensedfWnber Propieriy Owner CertWcatfoa 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,§22);(2)All showenccads,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 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 MOW 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, Qom— C r'a� &wtk ' Print Name o waer Sisnatum ofowner / ti _D Date 0 Date em ra The property has boa transferred to owner above and the unit eav rains in compliance with the p>aireraents of M.G.L.c. 186 22 Date: b BO�EB 21 2020 "THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBNIETERING CITY OF SALEM MDPH-CSPSubmcteriagForm,Rev 11-4-16 BOARD OF HEALTH MASSACBUSETTS DEPARTMENT OF PUBLIC HEALTH SUBIVIETERING OF WATER AND SEWER CERTIFICATION FORM *In accordance with M.G.L.c.1 96,§22 and 105 CMR 410.000.Minimum Stander6 of Fitness for Human Habitation (State Sanitary Code Chapter 12),till following dwelling unit is allgble for the imposition on the tend of a charge for water and/or sewer service. • PROPERTY INFORMATION+ Address: 205 Highland Ave 206 24 C !Town: Salem MA Zi Code.01970 EQIOIPMENT INSTALLAnON E4FORMATION 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 fcx water and/or sewer.The devices must meet the following specifications: Showerheads with maximum flow rate not to exceed 2 x�allons 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 1 din 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 Works Association or similar accredited association. A licensed plumber mast install the water closets and submetering equipment. Submetering equipment information: Master Meter Flexible Axis Manufacturer Model# Lloensed Plumber Certification Joseph Beile#euille 9793 12-16-2019 Print Name of Plumber License# 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 city/towu,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 submater. Signed under the pains and penalties of perjury, Si lure Licensed Plumber Property Owner Certification 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 submetcring 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,§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, ev�LiLLA,— a. 0),V— Cz &6-1 Print Name of Owner Z Signature of Owner p C3 The property has been transferred to owner above and the unit Date Received remains in campliatice with the VMhenmts 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 SUBMRTERING CITY OF SALEM MDPH-CSP Submctering Form,Rev 11.4-16 BOARD OF HEALTH r( C MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH SUBMIETERING OF WATER AND SEWER CERTIFICATION FORK •Ice accordance with M.G.L.c.186,§22 and 105 CM 410.000:Minimum Standards of Fitness for Human Habitation (State Sanitary Code Chapter 10,the following dwelling unit is eligible for the imposition an the tenants of a charge for water and/or sewer service. PROPERTY UVVORMATION —� Address: 205 Hr bland Ave 205 24 Ci /Town: Salem MA Zip Code:01970 EQUIPIMTM INSTALLATYON DWORNATION 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 fbllowing specifications: Sboweibeads with maximum flow rate not to exceed 2 x fallons per minute(2.5 gpm) Faucets with maximum now rate not to exceed 2 24 gallons per minute(2,2 gpm) Ultra-tow flush water closets(toilets)not to exceed l*to gallons per flash(1.6 So 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 socr edited association. A licensed plumber must install the water closets and submetering equipment. Submetering equipment information: pilaster Meter Flexible Axis - Manufacturer Model# Licensed Plumber CertiQentlon Joseph Belletemille 9793 12-16-2019 Print Name of Plumber - License# - Date- I certify that(check all that apply): tAll 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 di¢ea[y to a meter installed by a water company and,in accordance with M.G.E..c.136,§22(p),does not require the installation of a submeter. Signed under the pains and penalties of perjury, v Si of LicensedPhmrber Properly Owner Certification I certify That:(1)This dwelling unit is eligible for the imposition on the tenants of a charge for water arwar sewer usage in accordance with the water submetering law(MGL c.186,§22);(2)All shower heads,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 Abe dwelling unit was installed by a Geensed 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.e.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 natal agreement that clearly provides for the separate charging of water and/or sewer servicr,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 carder the pains and penalties of pcdwy. 4 [Z 4./c Print Name of Owner Si tare of Owner Date The property has been transferred to owner above and the unit t ived remains in liaricx with the uirements of MG.L.c, 186 22 Date: OH: FEB 21 202 *TEAS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBMETERING CITY OF SALEM MDPH-CSP Submetering Form,Pcv 11.4-16 BOARD OF HEALTH MASSACRUSET'TS DEPARTMENT OF PUBLIC HEALTH SUBIVIXTERING OF WATER AND SEWER CERTIFICATION FORM *tat accordance with M.G.L.e.186.§22 and 105 CMR 410.000.Mham um Standards of Fitness forHuman Habitation (State Sanitary Code Chapter U),the fallowing dwelling unit is eligible for the imposition on the tenants of a charge for watersa►dlorsewu Service. PROPERTY INFORMATION Address; 205 H hiand Ave 204 24 C' frown: Salem MA Z!p Code:01970 EQUU%U=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 fallowing specifieatioas: Sbowerheads with maximum flow rate not to exceed gallons per minute(2.5 gpm) Faucets with maximum flow rate not to exceed 2 gallons per minute(23 gpm) Uhra-tow flush water closets(toilets)not to exceed 1 °gallons per flush(1.6 gpQ The submetering equipment used to measure the quantity of water used for each dwelling unit and commas area must meet the standards of accuracy and testing of the American Water Works Association or similar accredited association. A licensed plumbs must install the water closets and submetering equipment, Submetcring equipment information: Master Meter Flexible Axis Manufacturer mom# L.imsed Plumber Certiticadon JOselah Bellefeuiile 9793 12-16 2019 Print Dame ofPiumber - License# Date 1 cettify 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 galls per Bush. The plumbing permit issued by the cityhown,if required,is attached. Cj 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 submeter. Signed under the pains and penalties of perjury, Sigrtatureof Licensed Phimber Property Owner Certifleation 1 certify that:(1)This dwelling unit is eligible for the imposition on the tenants ofa charge for water and/or sewer usage in accordance with the water submet cring law(MGL c.186,§22);(2)All showerheeds,faucets,and watw closets in this { dwelling unit are water conservation devices that meet the standards specified above;(3)The water submeter measuring i 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 for the separate charging orwater and/or sewer service,and a copy of this certification form;(6)That all information included on this certification is trw and accurate to the best of my knowledge. Signed under the pains and penalties of perjury, r , k cry �tf� �Z A. Itq Print Name of Owner Sialute of Owner t D Date ❑The property has been b=fetted to owner above and the unit Received remains in compliance with the regairemerits of M.G.L.c. 186 22 Date: BOH: FEB 21 202 *THIS FORM MUST BE FILED V41TH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBMETERING CITY OF SALEM MDPH-CSl SvbmeterurgForm,Rev 11-4-16 BOARD 0~HEALTH MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH SUBMETERIIYG 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 fcr the imposition on the tenants of a charge for water and/or sewer service. PROPERTY INFORMATION Address: 205 Highland Ave 203 #QF unih in h1do 24 a /Town: Salem MA Zip Code:01970 EQUIPMENT INSTALLATION INFORMATION 105 CMR 410.000 requires the installation ofwater conservation devices prior to a dwelling unit becoming eligible for the imposition on tenants of a charge for water and/or sewer.The devices trust meet the following specifications: f Showetheads with maximum flow rate not to exceed 2 x allotts pc minute(2S gpm) Faucets with maximum flow rate not to exceed 2 m gallons per minute(2.2 gpm) 1 Ultra-law flush water closets(toilets)not to exceed 16 a gallons per flush(1.6 gpf) f The submetering equipment used to measure the quantity of water used for each dwelling unit and common an most tweet 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 submetcring equipment. Submetering equipment information: Master Meter Flexible Axis Manufacturer Model# Licensed Phrmber Certification —� - Joseph Bellefeuille _ 97933 12-16-2019 Print Name of Plumber License# — Date I certify that(check all that apply): have installed the submeteting equipment listed above in accordance with accepted plumbing standards. I have installed one or more water closets not exceeding 1.6 gallons per flush. Detetmined 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 directly to a meter 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 n ga pains end penalties of perjury, a SjjMtuWof licensed thunber Property Otrtter 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 submetering law(MGL c. 186,§22);(2)All showencaads,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 fbM(6)That all information included on this certification is flue and accurate to the best of my knowledge. Signed under the pains and penalties of perjury, Sri- tLf Z l Ira t Print Name o Owner Sienature of Owner ,; - D Date ©'Ile property has been transferred to owner above and the unit Receiv retrains in liance with the wuirements of M.G.L,.c.186 22 Date: b Bo; - EB 2 120201 *THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBMET RING CITY( F SALEM MDPH-CSP Submeta gForm,Rev 114-16 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 CM R 4I0.000:Minimum Standards of Ftiness for Human Habitation (State Sanitary Code Chapter)n,the&Hawing dwelling unit is eligible for the imposition on the tenants of a charge for water and/or sewer service. PROPERTY INFORMATION Ad&=: 205 fthland AVe 202 no.in bid, 24 Ci tTown: Salem MA Z i Code•01970 EQOIPMSNT INSTALLATION YNFORMATION 105 CMR 410.000 requites 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 specification Showerbeads with maximum flow rate not to exceed 2 4,gallons per minute(2.5 Spin)Faucets with maximum flow rate not to exceed 2?" gallons per minute(2.2 gpm) UIRa-low flush water closets(toilets)not to exceed I*1Q gallons per flush(1.6 gpf) The submstering 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 submetaing equipment. Submetering equipment information: 'Master Meter Flexible Axis Manufacturer Model# Llceased Plumber Certification Joseph Beliefeuille 9793 12-16 2019 Print Name ofPhunber License# Date I certify that(check all that apply): have installed the submetering equipment listed above in accordance with accepted plumbing standards. RI 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. Theplumbing permit issued by the cityAawn,if required,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 of a submeter. Signed under the pains and peaalties of perjury, PA f' } d S' tore f ieensed Plumber Property Owner CerMeation I Certify that:(1)This dwelling unit is eligible for the imposition on the tenants ofa charge for water and/or sewer usage at accordance with the water suhmetering 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)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 submetcr 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 informatiton included on this certification is true and accurate to the best of my knowledge. Signed under the pains and penalties of perjury, tb"L a Q iZlf6/c Print Name of Owner Si store of r%wner a ._ Date Li O The party has been transferred to owner above and the unit Rcceived remains in SMliance with the m9tiftements of M.G.L.c. 186.422 Date: 1hVT1n"-LrrD "THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBMETERING CITY OF SALEM MDPH-CSP Submctering Form,Rev It-4-16 BOARD OF HEALTH MASSACHUSE77S DEPARTMENT OF PUBLIC HEALTH SUBMETERING OF WATER AND SEWER CERTIFICATION FORM *In accordance wish M.G.L.c.186,122 and 105 CMR 410.000:Minimum Standards of Fitness for Human Habitation {State Sanitary Code Chapter 11),the fallowing 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 201 4 Cityaoww. Salem MA Zi Code:019T0 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 s charge for water and/or 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 rate not to exceed 2 gallons per minute(22 gpm) Ultra-low flush water closets(toilets)not to exceed 1 6'e0 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 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 ii t.lcensed Plumber Certification dtieph l3ellefeuille 9793 12-16 2019 Print Name 4-Plumber - — License# Date F certify that(check all that apply): I 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 bush. DeW- in-I that existing water closets do not exceed 1.6 galloos 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. 186,122(p),does not require the installation of a submeter. Signed under the pains and penalties of perjury, v K -- Signature of •censed PlurAer 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 subrnetering law(MGL c.186,§22);(2)All showeAcads,foueels,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 ofwater in this dwelling unit was installed by a"water company' as defined in M.G.L.c.186,12Z; (4)The water meter or submeter messures the water usage exclusive to Ibis 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, a4— ,, j Print Name of Owner Signature of Owner a D D ate ©'Me property has been transferred to owner above and the unit eived remains in emm Hance with the rennirements of M.G.L.c. l8 22 Date: ''' 1. 202 *THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBMETERING CITY OF SALEM MDPH-MP Submctering Fome,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 an the tenants of a charge for water and/or sewer service. _Y PROPERTY INFORMATI___ON Andress: 205 Hl bland Ave 108 24 city/Town: Setetrl MA Zip Code:01970 EQUlPMM UWALLATION 1NFORMAnON 105 CMR 410.000 requires the installation of water conservation devices prior to a dwelling unit becoming eligible far the imposition an tenants of a charge for water and/or sewer.The devices must meet the following specifications; Shvwerheads with mae==flow rate not to exceed 2 gjaflons per minute(2.5 gpm) Faucets with maximum flow rate not to exceed 2 — ons per minute(2.2 gpm) Ultra-low flush water closets(toilets)not to exceed 1600 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 Wodm 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 Bellefeuille 9799 12-16-2019 Perot Name of Plumber License# 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 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.I.,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 Cartititatlon -- I certify that:(1)This dwelling unit is eligible for the imposition an the tenants of a charge for water and/or sewer usage in accordance with the water submetering law(MGL e.186,§22r(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.e.186,§22; (4)Ile water meter or submeter measures.the water usage exclusive to this unit;(5)1 will provide to the tenants of this dwelling unit,prim 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 UowrL Z2 f Print Name of Owner Signature of Owner Date l7 7 be property has been transferred to owner above and the unit Received remains in coin fiance with the ru[ �ndrls of M.G.L.tw f85._§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-CSP SubraeteringForm,Rev 11-416 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 far 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--- Addtrss: 205 Highland Ave 107 f, • a 24 City/fawn: Salem MA Zi-)Code•01970 EQU PMENT INSTALLATION 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 for water and/or sewer.The devices must meet the inllowing specifications: Sbowerheads with maximum flow rate not to exceed 2 Ualtons 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 1 d1e gallons per Bush(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 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 Certiflcation Joseph Wlefoullle 9793 12-16-2019 Print Name of Pluuaber License# Date I certify that(check all that apply): MI have installed the submeteriug 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. A. Signed under the pains and penalties of perjury, 9A, S' lure of Li Phmuber�� Property Owner Card ication l certify that:(1)This dwelling unit is eligible for the imposition on the tenants of a charge for water andfor sewer usage in accordance with the water submetering law(MOL c.186,§22);(2)All showedu ds,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;(S)I will provide to the tenants of this dwelling unit,prior to occupancy,a written mental agreement that clearly provides for the separate charging orwater 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 ofpedury, I ®� QS�. ca Qs (3or- ,. J Ld°`�.� Print Name of Owner Si>rnature of Owner e D Date C The property has been transferred to owner above and the unit Received FEB 2 1202 remains in compliance with the reaniruuneafs of MG.I, a 186 22 Date: by SOH: 'THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING S �lALEM BOARD OF HEALTH MI)PH-CS?Submeteriug Form,Rev 11-4-16 MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH SUBMETERING OF WATER AND SEWER CERTIFICATION FORM ;In accordance with M.G.L.c.1116,§22 and 105 CMR 410.000.Minimum Staudants of Fitness far Human Habitation (State Sanitary Code Chapter 11),the following dwellinng unit is eligible for the imposition on the tenants of a charge for water and/or sewer service. PROPERTY INFORMATION Address: 205 H hland Ave Urra g4106 24 C' frown: S818M MA Zip Code:01970 EQltfiP'IiIENT 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 for water and/or sewer.The devices must meet the following specifications: Sbowetheads with maximum flow rate not to exceed 2 X�allons per minute(2.5 gpm) Faucets with maximum flow rate not to exceed 2 gallons per minute(2.2 gpm) a Ultra-low flush water closets(toilets)not to exceed 1 6'10 gallons per!lush(Ld 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 Worics Association or similar accredited association. A licensed plumber must install the water closets and submetering equipmeuL Submete ing equipment itnfatmation: Master Meter Flexible Axis Manufacturer Model# Llcessed Plumber Certifleadon --�— - — Joseph Betleteuills _ 9793 12-16 2019 Print Namur of Plumber � � License#� Date I certify that(cluck all that apply): MI have installed the submeteting 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 requite the installation of a submeter. Signed under the pains and penalties of perjury, r Si ofLicensed Mumber 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 submetering law(MGL c.IN,§22);(2)All showenceads,faucets,and water closets in this dwelling unit arm water conservation devices that meet the standards specified above;(3)The water sabmeter 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 water 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 pmvidas for the I separate charging of water and/or sewer service,and a copy of this certification foam;(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 perjuty, s� k2 D Print Name of Owner Sitrnature of Owner Date C3 The property has been transfetted to owner above and the unit Received remains in ca lianee with the uirements of M.G.L.c. 186 22 Date: b BOH: FEB 21 20 0 °THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SU�MKALEM MDPFI-CSP Sutrmctering Form,luau 114-16 BOARD OF HEALTH MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTIi 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 can the tmamts of a charge for water and/or sewer service. PROPERTY INFORMATION Address: 205 Highland Ave 11ma A106 it orugim in hLig 24 C' Irown: Salem MA zi Code:01970 EQUIPM$NT INSTALLATION 1NFORMATION 105 CMR 410.000 requires the installation of water conservation devices prise to a dwelling unit becoming eligible for the imposition an teaeots of a charge for water and/or sewer.The devices must meet the following specifications: Showedmds with maximum flow rate not to exceed 2 u� m)'*'_gallons per minute(2.5 gp Faucets with maximum flow rate not to exceed 2 gallons per minute(2.2 gpm) Ultra-low Mob water closets(toilets)not to exceed I'0w gallons per flush CIA gpd) 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 associadom. A licensed plumber must install the water closets and submetcrimg equipment. Flexible Axis Submeterimg equipment information: Master Meter .. Manufacturer Model# Licensed Plumber Certification Joseph Bellefeuille 9793 12-16-2019 Print Name of Plumber Licensc# Date I cerdfy that(check all that apply): XV 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 required,is attacked. [�Dwelling unit is connected directly to a meter installed by a water company and,in accordance with M.G.L.G 186,§22(p),does not require the installation of a submeter. Signed under the pains and penalties of perjury, ` n ~ _ Si tune of Licensed ph=ber Property Owner Certification I certify lust:(1)This dwelling unit is eligible for the imposition on the tenants of a charge far water mWor sewer usage in accordance with the water submatering law(MGL c.186,§22);(2)All showenccads,faucets,and water closets in this dwelling unit are wager 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)7be water meter or submeter measuros the water usage exclusive to this unit,(5)I will provide to the tenants of this dwelling unit,prior to occupancy,a written rental agroemcnt 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 ofperjury, lltt t .s11R-oi f— �2-f 16/(� Print Name of Owner 7 JSignature of Owner Date 0'Ibc property has been ttansfen:ed to owner above and tie unit Received remains in compliance with the uirements of M.G.L.c.186 22 Date: b BOBFEBJ 120201 *THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INMANNG SUBMETERING CITY OF-SALEM MDPH-CSP Submetering Form,Ray 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.1116,§22 and lOS 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 tenaaLs of a charge for watfi-,flivdf sewn.aeeryice. ~ PROPERTY INFORMATION Address: 205 Highland Ave uat 0104 V Ckf jordft in bid@24 ` lfown: Salem MA Zi Code:01970 EQUIP&SM INSTALLATION DWORMATION 105 CMR 410.000 requires the installation of crater 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: Showerheads with maximum flow rate not to exceed 2 e�allons per minute(2.5 spin) 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 *`10 gallons per flush(I.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 accwacy and testing of the American Water Wod6 Association or similar accredited association. A Iicensed plumber must install the water closets and submetering aquipmeaL Submetecing equipment information: Master Motor Flexible Axis Manufleeturer - Model# Licensed Plumber Certi cation Joseph Seilefeuille 9793 12-16-2019 Print Name of Plumber License# Date I certify that(check all that apply): I have installed thc 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 cityttown,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 perjrny, . . Si ature hT Licensed Plumber Property Owner Certifleaden 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 submeta ft 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)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;(S)I will provide to the tenants of this dwelling unit,prior to occupancy,a wfitten 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 infomration included on this certification is true and accurate to the best of my knowledge. Signed under the pains and penalties of perjury, f Print Name of Owner 5ierrature of owner it Date The property has been transferred to owner above and the unit Received remains is can liance with the requirements of M.G.L.c. 18 22 Date: h SoH: FEB 2 120 *THIS FORM MUST BE FILED WITH TILE LOCAL BOARD OF HEALTH PRIOR TO INMA71NG SUBIVIETERING CITY OF SALEM MDPH-CSPSubmeteringFarm,Rev 11.4-16 BOARD OF HEALTH n MASSACHUSE77S DEPARTMENT OF PUBLIC HEALTH SUBMETERING OF WATER AND SEWER CERTIFICATION FORM *1n accanlance with M.G.L.c.186,§22 and 105 CMR 410.000.Minimum Standards of Faness 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 INFORMATION _ k Address: 205 Highland Ave i iO3 soaranits in hidy 24 ci!xrrown: Salem MA 2i code:01970 EQDIPUMNT 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 r1lons per minute(2.5 gpm) Faucets with maximum flow rate not to exceed 2 an gallonsper minute(2.2 gpm) Ultra-low flush water closets(toilets)not to exceed 1 d+t0 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 simiiar accredited association. A Iicensed plumber must install the water closets and submetering equipment. Submetering equipment information: Master Meter Flexible Axis hunufacturer Mabel# I.ia sed Plumber Certificadon Joseph Belle€truffle_ 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 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!etury. & 1 i Sic ed Plumber Property Owner Certification I certify that:(1)This dwelling unit is eligible for the imposition an the tenants of a charge far water and/or sewer usage in accordance with the water submctering law(MGL c. 186,§22);(2)All showcAeads,faucets,and water closets in this dwelling unit art 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'tivater company' as defined in M.G.L.c. 186,§22; (4)The water meter or submeter measures the water usage exclusive to this unite(5)1 will provide to tltc 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 fo n;(6)That all information included on this certification is true and accurate to the best of my Imowledge. Signed under the pains and penalties of petjtuy, L -ws - or ' - (2/ Zia- Print Name of Owner 17 Signature of Owner Date 0 The property has been transfenvd to owner above and the unit Received remains in compliance with the rcquirements of M.G.L.c. 186 §n Date: by HOH.FEB 21 202 *THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIORTO INITIATING SURToR1RALEM MDPH-CSPSubmeteringForm,Rev 11-4-16 BOARD OF HEALTH MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH SUBMETERING OF WATER AND SEWER CERTIFICATION FORM *1n accordance with M.G.L.c.1116,122 and 105 CMR 410.000:Minimum Standards of Fitness far Human Habitation (State Sanitary Code Chapter In,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 jai t A_102 24 g rrown: Salem MA Zip Code:01970 EQUIPMENTI STALLATIONINFORMATION 105 CMR 410.000 requires the installation ofwater conservation devices prim to a dwelling unit becoming eligible for the imposition on tenants ofa charge for water and/or sewer.The devices must meet the fallowing specifications: Sbowciheads with maximum flow rate not to exceed 2%gallons per minute(2.5 gpm) Faucets with maximum flow rate not to exceed Z 2M gallons per minute(2.2 gpm) [Jura-tow flush water closets(toilets)not to exceed 16'10 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 Wodcs Association or similar accredited association. A licensed plumber must install the water closes and submetering equipment. Submetering equipment information: Master Meter Flexible A1ds Manufacturer Model# Licea"Plumber Certlf)cation Joseph Bellefoulile 9793 12.16-2019 That 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 ofa submeter. Signed under the pains and penalties of pequry, L AV Siwuluiv of LicensedPlumber 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 shows f=&,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 defied 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 truc and accurate to the best of my knowledge. Signed under the pains and penalties of perjury, r S,— L6A as &J, 0 ZIL Print Name of Owner Signature of Owner Date The property has been traanssfened to owner above and the unit Reiceived FEB 21 202 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 StR{7 GAS`=M 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 INFiORAUTION Address: 205 Highland Ave 101 24 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 fblk wWg specifications: Showetbeads with maximum flow rate not to exceed 2 x gallons per minute(2.5 Spin) Faucets with maximum flow rate not to exceed 2 m gallons per minute(2.2 Spin) Ultra-low flush water closets(toilets)not to exceed 1,010 gallons per fhish(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 Certiffcatlbn - Jtmph Beilefeuiile 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 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.186,1 22(p),does not require the installation of a submeter. Signed under the pains and penalties of perjury, 14-4 !' ►}• SipatuA of Licensed Nwnber 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)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 hue and accurate,to the best of my knowledge. Signed under the pains and penalties of perjury, Print Name of Owner ignature of Owner Date Q The property has been transfeaed to owner above and the unit Received rr„ains in SMpliance with the teguirements 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 SU CMETERIV%-ALEM MDPH-CSPSubmctedngFarm,Rev 11.4-16 BOARD OF HEALTH