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Water submeter certificates - Units in the 5s 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 (gtate Sanitary Code Chapter]A the fallowing dwelling unit is eligible for the imposition an the tenants ofa charge for water and/or sewer service. PROPERTY INFORMATION Address: 205 Highland Ave 24 frown: S910M MA Zi Code:01970 EQUIPMENT INSTALLATION INFORMATION 105 CMR 410.000 requires the installation of water conservation devices prior to a dwelling unit becoming eligible for the imposition on tenants ofa charge for water and/or sewer.The devices must meet the fallowiog specifications: Showetbeads 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-pow flush water closets(tollets)not to exceed 1 era gallons per flush(1.6 gp0 The submewft 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 Licensed Plumber Certification ication Jowph Belleteuilie 9793 12-16-2019 - Prim Name of Plumber ^ License at{ 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 cityAown,if required,is attached. ❑Dwelling unit is corrected dizectly to a meta 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, _ Sismanue of Licensed Plumber Property Owner Certification l 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 c.186,§22);(2)All showarbcads,faucets,and water closets in this dwelling unit arc water conservation devices that meet the standards specified above,(3)The water subemeter measuring the use of water in the dwelling unit was installed by a licensed plumber and is in compliaocc 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 written rental agreement that clearly provides for the separate charging of water and/or sewer service,and a copy of this certification font;(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, 9 I r.�.1-2f i- 1A, 12-®L A"1 Print Name or Owner ! Signature of Owner a D Date The property has been transferred to owner above and the unit Received remains in compliance with the requirements or M.G.L.a 166 22 Date: lbyBOH:FFR 'THIS FORMA MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBMEfERING CITY OF MDPH-CSP SubmetezingForm,Rev 11-4-16 BOARD OF HEALTH MASSACIRUSETTS DEPARTKENT 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 Humus habitation (3taw Sanitary Code Chapter II),the following aweiling unit is eugibtc tar the apposition on the tenants of a charge for water and/or sewer service. PROPERTY INFORKATION Address: 205 H hlartd Ave , • 5307 . Cf un;U!a bid,24 --- a flown: Salem MA Zip Code:01970 EQEVMENT E%TALLATION 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: Showetheads with maximum flow rate not to exceed 2:01ons per minute(L5 gpm) Faucets with maximum flow raft not to exceed 2 gallons per minute(2.2 gpm) Ultra-low flush water closets(toilets)not to exceed 1 told 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 si miluaccredited association. A licensed plumber must install the water closets and submeteriag equipment Submetering equipment information: Master deter Flexible Axis ---_ Manufacturer Made)# Licensed Plumber Certification Joseph Beileieullle _ 9793 12-16 2019 Print Name of?l=ber License# —Date 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 cityltown,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, — -- �--- Siolaturc of Licensed Pltn fiber 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 submateritig law(MGL c.186,§22);(2)All showenccads,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"water company" as defined in M.G.L.c.186.§22; (4)The water meter or submeter measures the water usagc 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 form;(6)That all infottmation included on this certification is troe and accurate to the best of my knowledge. Signed under the pains and penalties ofperjury, Sea. as iZ-l6 Print Name of Owner 9i awe of Owner t D Tb ]ate 0The property has been transfeaed to owner above and the unit eceived remains in caps liana with the uitements of MG.L.r;186 22 Date: BOH: r F B `1 1 9 Q In *THIS FORM MUST BE FILED WITH THE LOCAL BOARD Of HEALTH PRIOR TO INITIATING SUBMETERING CITY OF SALEM MDPH-MP Submeledug Form,Rev 11.4-16 BOARD OF HEALTH - T MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH SUBIvIETERFNG OF WATER AND SEWER CERT WICATION 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 12),the hollowing dwelling twit rs eligible for the imposition an the wa:mts ofa charge for water and/or sewer service. PROPERTY IMORIHATION Address: 205 H' hlerul Ave --Unit 306 inruniminhmg 24 ' rl'own: Sateen MA Zip Code:01970 EQUIPI Mff INSTALLATION INFORMATION 105 CIVIR 410.000 requires the installation of water conservation devices prior to a dwelling unit becoming eligible for the imposition an tenants ofa charge for water and/or sewer.The devices must meet the following specocations: Sbowedweads with maximum flow rate not to exceed 2 x jAlons per minute(2.5 gpm) Faucets with maximum flow rate not to exceed 2 2n gallons per minute(2.2 gpm) Uhm-low,flush water closets(toilets)not to exceed l&10 gallons per flush(1.6 gp0 The submetering equipment used to measure the quantity of water used for earl,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 infatuation: _ Master Meter Flexible Axis Manufacturer Model# Licensed Plumber Certllleatlon Joseph Bellefeuille 9793 12_-1 hi-2019 Print Name of Plumber License# Date I cescify 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, v Sim+sture of Licensed fhqft Properly Owner Certification 1 cert*that:(1)This dwelling unit is eligible for the imposition on the tenants ofa charge for water andfor sewer usage in accordance with the water submetering haw(MGL c.186,§22);(2)All showenccads,faucets,and waterclosets in this dwelling unit awe water conservation devices that meet the standards specified above;(3)The water suboweter measuring the use of water in the dwelling unit was installed by a licensed plumber and is in compliance with the standards !1 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 fmnw;(6)That all information included on this certification is tine and accurate to the best of my Iatowledge. Signed under tie pains and penalties of perjury, Q . Print Name of Owner Shmature of owner Date C3 The property has been traosfeaed to owner above and the unit Received remains in compliance with the m1untamts of M.G.L.c 186 22 Date: by BofFEB `,THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBMETERING CITY a SALEM MDPH-CSFSubmeteringFomyRev 11.4-16 BOARD OF HEALTH MASSACHUSETTS DEPARTMENT OF Pt7BLIC HEALTH SUBMETERING OF WATER AND SEWER CERTIFICATION FORM *In accordance with M.G.L.c.1 B6,§22 and 105 CMR 410.000.Minimum Standards of Fitness for Humus Habitation (State Sanitary Code Chapter M,the Lnllowtog dwelling unit is eligible for the imposition on the tenants of a charge for water and/or sewer service. PROPERTY INFORMATION Address: 205111ghlandAye Unit#5305 24 city/Town. Salem MA Zi Code:01970 EQLJUSM4T EMALLATION 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 fair water and/or sewer.The devices must meet the following specifications: Sbowerheads with maximum flow rate not to exceed 2 a 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 gallons per flush(1.6 gpf) The submetering equipment used to measurj°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. Submate ring equipment information: Master Meter Flexible Axis - - --- -. Manufacturer Model# Uceased Phember Certification Joseph Be3llefeullle 9793 12-16-2019 Print Name of Plumber License 4 Date rm, (check all that apply): avenstalled 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 Hush. J Determined that existing water closets do not exceed 1.6 gallons per Hush. li The plumbing permit issued by the city/town,if required,is attached ❑Dwoliing unit is connected directly to a rester installed by a water company and,in accordance with M.G.L.c. 186,§22(p),does not require the installation of a submcter. Signed tutder the pales and penalties of perj ury, Si lure f Lieessed Plumber Prapt:rtp 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 submetaing law(MGL c.186,§22);(2)All showerheads,faucet&,and water closets in this dwelling unit ale 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 deter or submctcr 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 form;(6)That all information included on this certification is true and accurate to the best of my knowledge. Signed tinder the pains and penalties ofperjuty, 5116% Print Name of Owner SienaWa of Owner R e Date The property has been ttansfetrsd to owner above and the unit Received remains in liatree with the rvouiretrterits of M.G.I. c. l86 22 Date: b BOIF. *THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBMETERING CITY OF SALEM MDPH-CSPSubmeteringForm,ltev 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 a),the following 4wwelling ru h is ciigibie Tar-lire hupusidun un the icnauts of a chargo for water and/or sewer service. PROPERTY INFORMATION Address: 205 Highland Ave 04 inim it,hid,24 citytrown. Salem MA zi Code:01970 EQUIPMENT INSTALLATION INFORMATION 105 CMR 410.000 requires the installation of water conservation devices prior to a dwelling unit becoming eligible for the imposition on tenants of a charge for water and/or sewer.The devices must meet the following specifications: Sbowerheads with maximum flow rate not to exceed 2 x jallons per minute(2.5 gpm) Faucets with maximum flow rate not to exceed 2 an gallons per minute(22 gpm) Uhm-low flush water closets(toilets)not to exceed t 6rE0 gallons per flush(1.6 gp f) The submetering equipment used to measure the quantity of water used for each dwelling unit and common arse must cunt 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 submeteting equipment Submetering equipment information: Master Meter Flexible A)ds Manufachaw Model tY - Licensed Plumber Cerliileation Joseph Beilefeuille 9793 12-16-2019 Print Name of Plumber License 0 — - bate I certify that(cheek all that apply): UM 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 comteeted 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, ` y Siviature of Licensed Plumber --- - — — Property Owner Certification t 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 suubmctering law(MGL c.186,§22);(2)All showedmads,faucets,and wa mclosets in this dwelling unit are water conservation devices that meet the standards specified above;(3)The water submeter measuring the we of water in the dwelling unit was installed by a licensed plumber and is in compliiamcc 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 taut;(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 ofwater 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 perjury, J Print Name of Owner Simature of Owner .H to D If Date Tbc property bas been trensfetsed to owner above and the unit i Received remains in compliance with the requirements of M.G.L.c.196 §22 Date: _y 130H: FEB 21 20:0 *THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INMA nNG SUl1METERING CITY OF SALEM MDPH-CSP Submetering Form,Rev 11-4-16 BOARD OF HEALTH MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH SUBMETERING OF WATER AND SEWER CERTIFICATION FORM *In accordance with M.G.L.c.186,§22 and 105 CMR 4I0.000:Minimum Standards of Fitness for Humor 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 unit#5303 24 qrTown: Salem MA Zi Code:01970 EQUIPMENT INSTALLATION INFORMATION 105 CMR 410.000 requires the installation of water conservation devices prior to a dwelling unit becoming eligible for the imposition on tenants of a charge for water and/or sewer.The devices must meet the following specifications: Sbowerheads 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(22 gpm) Ultra-low,flush water closets(toilets)not to exceed 1 610 gallons per flush(1.6 gpf) j The submctering equipment used to measure the quantity of water used for each dwelling unit and common area must l meet the standards of accuracy and testing of the American Water Works Association or similar accredited association. 1 A Iicextsed plumber must install the water closets and submetering equipment. 1 Submeter ng equipment infomntion: Master Meter Flexible Axis -- Manufacturer Licensed Plumber CertMeation Jamph Hellefetliile 9793 12-16-_20_19 Print Name of Plumber - - License# - - Date I certify that(check all that apply): L 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 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. 1116,122(p),does not require the installation of a submeter. Signed under the pales and penalties of perjury, Signature or Licensed Phanber Property Owner Cer iticadoa 1 certify tbat:(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 subaatering law(MGL c.186,§22);(2)All showcrhesds,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.186,122; (4)The water meter or submeler nicasures 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 fornr(6)That all information included on this certification is true and accurate to the best of my knowledge» Signed under the pains and penalties of perjury, a (ke e Print Name of weer Si arum of Owner D Date The property has been traasfarred to owner above and the unit Receivedem rains in compliance with the rwti tement5 of M.G.L..c. 186 22 Date: by 13OH: FEB 21 20 *THIS FORM MUST BE FILED WITHTHE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBMt TER1NG CITY OF SALEM MDPH-CSP SubmctaingForm,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.196.§22 and 105 CMR 410.000:Minimum Standards of Fitness for Huu mn Ftahitarim 13tate Sanitary Lode Chapter D),the hallowing dwelling 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 5302 24 Ci frown: Salem MA Zia Code!01970 EQUIPMENT INSTALLATION INFORMATION 105 CMR 410.000 requires the installation of water conservation devices prim to a dwelling unit becoming eligible far the imposition an tenants of a charge for water and/or sewer.The devices must meet the fngowing specifications: Sbowerbeads with maximum flow rate not to exceed 2%fallons 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 closets(toilets)not to exceed 1 6'10 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 Worlts Association or similar accredited association. A licensed plumber must install the water closets and submetering equipment. Submetaing equipment information: Master Meter Flexible Axis — --_ Manufacturer Model# Licensed Piumhes Cermcatiom Joseph Bellefouille 9793 12-16-2019 Print Name of Phuber - License# — - - Date I certify that(ebeck ail 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 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, ram: f _ SiNhature off.icensed Plumber Property Owner Certification 1 certify that:(1)This dwelling unit is eligible for the imposition an the tenants of a charge for water sailor sewer usage in accordance with the water submetering law(MGL c. 186,§22);(2)Ali 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`%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)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 luau and accurate to the best of my knowledge- Signed under the pains and penalties ofperjuty, IL-L-. &.,L-��- 0- v ao'— k2-A Print Name of Owner Si tore of Owner - D Date ❑The property has been transferred to owner above and the unit Received remains in con liance with the Eguirernents of M.G.L.a 196 22 Date: by BOH: FEB 2 1 202 *THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBMETERING CITY OF SALEM MDPH•CSP SubmeteringFemy Rev 11.4-16 BOARD OF HEALTH MASSACHUSE17S DEPARTMENT OF PUBLIC HEALTH SUBM ETERING 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 following dwelling unit is eligible for the imposition on the tenants of a charge for water and/or sewer service. PROPERTY UOVRKA77ON Address: 205 Highland Ave TLut 0301 24 Ci rrown: Salem MA Zl Code:01870 EQUIPMENT INSTALLATION INFORMATION 105 CMR410.000 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 Hollowing specifications: Sbowaheads with maximum flow rate not to exceed 2 K alIons per minute(2.5 gpm) Faucets with maximum flow rate not to exceed 2 gallons per minute(2-2 gom) Ultra-low flrtsh water closets{toilets)not to acceded 1 W°gallons per flush(1.6 gpt) The submetering equipment used to measure the quantity of water used for each dwelling unit and comaron 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 McXil le AXIS _ Manufacturer Model# Llceased Plumber CertEcation Joseph Bellefeuille 9793 12-16-201 s Print Name of Plumber License# Date I certify that(chock all that apply): I have installed the submetering equipment listed above in accordance with accepted plumbing standuft I have installed date 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 cityRown,if required,is attached. ❑Dwelling unit is connected directly to a meter installed by a water company and,in accordance with M.G.L.c.186.§22(p).does not require the installation of a submeter. Signed under the pains and penalties of perjury. —_-�-- _ V SiwnaturcorUcensedPlumber Property Owner Certification I certify War(1)This dwelling unit is eligible for the imposition on the tenants of a charge for water and/or sewer usage in accordance with the water submetering law(MGL c.186,§22);(2)All showerheads,faucets,and water closets in this dwelling unit am 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 We 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 usagc 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, cam ` Print Name of Owner Simtature of Owner Pt Date O The property has been transferred to owner above and the unit Received remains in c aim liana with the rvxrerirrraents of M.G.L.c.t86 22 Date: by BOR FEB 21 20 0 °THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBMETERING CITY OF MDPH-CSPSubmateringForm,Rev 11.446 BOARD OF HEALTH MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH SUBMET ERING OF WATER AND SEWER CERTIFICATION FORM *In accordance with M.G.L.c.186,§22 and 105 CMR 410.000:Minimums Standards of Fitness for Human Habitation (State Sanitary Code Chapter II),the fallowing dwelling unit is eligible for the imposition on the tenants ofa charge for water and/or sewer service. - PROPERTY INFORMATION Add: 205 Highland Ave unit 115208 a Qf.mts in hWg.24 Citv/Town: Salem MA ?i �p Code:01970 EQUIPbM4T INSTALLAnON INFORMATION 105 CMR 410.000 requites 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 specifications: Showerheads with maximum flow rate not to exceed 2�11ons per minute(L5 gpm) Faucets with maximum flow rate not to exceed 2 gallons per minute(2.2 gpm) [Ultra-tow flush water closets(toilets)not to emceed f 6"0 gallons per flush(1_6 gpf) The subme►aing 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 inforRmatioo: _ Master Meter Flexible Aids Manufhetuter Model# —- Licensed Plumber Cerdilca�n _ Joseph Bellefeuilie _ _ 9793 12-16 2019 Print Name of Plumber License# Date I cectiFy that(chock 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 lush. Determined that existing water closets do not emceed 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.c.186,§22(p),does not require the installation ofa submeter. Signed under the pains and penalties of perjury, Si of Licensed Phan er Property Owner Certitieation I certify that:(1)This dwelling unit is eligible for the imposition on the tenants ofa charge fur water and/or sewer usage in accordance with the water submatering law(MGL e.186,§22);(2)All showabeads,faucets,and water closets in this dwelling unit are water conservation devises 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 rot the separate charging orwater and/or sewer service,and a copy of this certification farm;(6)That all information included an this certification is ante and accurate to the best of my knowledge. Signed under the pains and penalties ofperjury, O te�C- :� 06,w~ m Print Name of Owner Signature of Owner Date The property has been transfetred to owner above and the unit Received remains in compliance with the rwitirements of M.G.L.c. 186 22 Date: _ by BOB *THIS FORM MUST BE FILED WITH THE LOCAL BOARD Of HEALTH PRIOR TO INITIATING SUBN{ETERING CITY OF SALEM MDPH-CSP Submctering 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 10S CMR 410.000:Minimum Standards of Fitness for Human Habitation (Slate Sanitary Code Chapter 11),the fnliowing 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 -UnLAL5207 ii anahiLw& 24 Ci down: Salem MA Zi Code:01970 EQUIPMENT INSTALLATION EWORMATION 105 CMR 410.000 requires the installation of water conservation devices prior to a dwelling unit becoming eligible far the imposition on temnts of a charge for water and/or sewer.The devices must meet the following specifications: Sbowaheada with maximum flow rate not to exceed 2'c gallons per minute(2.5 gpm) Faucets with maximum flow fate not to exceed 2 2n gallons per minute(2.2 gpm) infra-low flush water clown(toilets)not to exceed 1 6"'o gallons per flush(1.6 Spf) The submetering equipment used to measure the quantity of water used for each dwelling unit and common area must mod the standards of accuracy and testing of the American Water Waft Association or similar accredited association. A licensed plumber must install the water closets and submetering equipment. Submetering equipment informfation: Master dater Flexible Axis Manulhcu ex Model# Licensed Plumber Certlticatlon Joseph Bellefeuille 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 mote 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 I ❑Dwelling unit is connected directly to a nutter installed by a water company and,in accordance with M.G.L.c.1116,§22(p),does not require the installation of a submeter. Signed under the pains and penalties of pcdwy, Si orate Licensed Pltanber 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 submetering law(MGL c.186,§22),(2)All showerbeads,faucets,and waterclosets 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 fspecified 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 meta ar 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 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 of pcduty, Print Name of Owner 17 Sie nature of Owner D Date 13 The property has been transferred to owner above and the unit Received remains in fiance with the ffirements of M.G.L.c. 186 2z Date: BOHFEB 2 120201 *THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF WEALTH PRIOR TO INITIATING SUBMETERING CITY Or SALEM MDPH-CSP Submetering Farm,Rev 11-4-16 BOAR?OF HEALTH MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH SUBMETERI.NG OF WATER AND SEWER CERTIFICATION FORM *In accordance with M.G.L.c.IRS.§22 and 105 CMR 4I0.000.Minimum Standards of Fitness for Henan Habitation (State Sanitary Code Cbapta 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 hlarld Ave 5206 24 frown: Salem MA Zi Code:01970 EQNT 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 for water and/or sewer.The devices must meet the following specifications: Sbowerheads with maximum flow rate not to exceed 2't fallons per minute CLS gpm) Faucets with maximum flow rate not to exceed 2 s" gallons per minute(2.2$pm) Ultra-tow flush water closets(toilets)not to exceed I er>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 similar accredited association. A licensed plumber must install the water closets and submetering equipment Subaatering equipment information: Master Meter Flexible Axis Manufacturer Model# Licensed Plumber Cerd0catiou ^_ Joseph Bellefeuille 9793 12-16-2019 Print Name of Plumber — _ — License# — - Date I certify that(check all that apply): rolI 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 attached. ❑Dwelling unit is connected directly to a meter installed by a water company and,in accordance with M.G.L.c. 196,122(p),does not require the installation of a submeter. Signed under the pains and penalties of perj ury, n - Si�m�o�fiied her Prop"Owner Certification I certify that:(1)This dwelling unit is eligible for the imposition on the tenants of a charge fern water and/or sewer usage in accordancc with the water submetering taw(MGL c.186,§22);(2)All showedmads,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'%Yatcr company„ as defined in M.G.L.c.196,122; (4)The water meter or submeter measures the water usage exclusive to this twit;(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 ender the pains and penalties ofperjury, A. DPrint Name of Owner Signature of Owner P I.V411w- Date �The property has ban transferred to owner above and the unit Received remains in con liance with the:requirements of M.G.I..c. 186,122 Date: b BOH: FEB 2 1 202 *THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIORTO INITIATING SUBMETERING CITY OF SALEM MDFH-CS?SubowtedugForm,Rev 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 CM8 410.000:Minimum Standards of Fitness for Human Habitation (State Sanitary Code Chapter U),the Endowing 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 • 52D5 24 Ci rliown: Salem MA 2i Code•D19TD EQUIPMENT INSTALLATION 114FORrAATION 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 fallowing specifications: Showexheads with maximum flow rate not to exceed 2 u�allons per minute(2.5 gpm) Faucets with maximum flow rate not to exceed 2 gallons per minute(2.2 gpm) Ultra-low Bush water closets(toilets)not to exceed 16t10 gallons per flush(1.6 gp f) 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 equipmeat. Submetering equipment information: Master Meter Flexible Axis Manufacturer Model# r icensed Phu nber Certification Joseph Bellefeuille 9793 12-16-2019 Print Name of Plumber License# Date 1 certify,that(check all that apply): ;have installed the submetering equipment listed above in accordance with accepted plumbing standards. 1 have installed one or mots 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,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, Y^ 4 d Sizeature e Licensed PhuMer 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 suubmetering law(MGL c.186,§22);(2)All showerlueads,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 submreter measures the water usage exclusive to this unit;(5)1 will provide to the tenants of this dwelling unit,prior to occupancy,a written frontal agm=mt that clearly Provides for the separate charging of water and/or sewer service,and a copy of this certification fermi;(6)That all infomnation included on this certification is true and accurate to the best of my knowledge. Signed under the pains and penalties of per jury. "at &I f Z Ave Print Name of Owner Sienature of Owner Date 0 The property has been transferred to owner above and the unit Received rernaigns in cam liana with the mgmirernents of M.G.L.c. 186 22 Date: by BOW F *THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATiNG SUBMETERING CITY OF SALEM MDPH-CSP Subtacte:ting Form,Rev It 4-16 BOARD OF HEALTH MASSAC19USETTS DEPARTMENT OF PUBLIC HEALTH SUBMETERING OF WATER AND SEWER CERTIFICATION(FORM •Ia accordance with M.G.L.c.186,§22 and 105 CMR 410.000:Minimum S tandards of Fitness far Huffman Habitation (State Sa"my 4o+ic i:hapeer A),rise miiowimg dwelling unit is eligsbte for the imposition on the tenants of a cbarge for water and/or sewer service. PROPERTY INFORMATION Address: 205 Highland Ave I in et 24 a /Town: Salem MA Zi Code:01970 EQUIP143;N'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 teaaats of a charge for water and/or sewer.The devices must meet the fallowing specifications: Sbowerheads with maximum flow rate not to exceed 2:Ilona per minute(2.5 gpm) Faucets with maximum flow rate not to exceed 2 gallons per minute(2.2 gpm) Ulna-low flush water closets(toilets)not to exceed 1 quo 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 Works Association or similar accredited association. A licensed plumber must install the water closets and submetering equipment. Submetering equipment information: Raster Meter Flexible Axis Manufacturer Y Model/! Licensed Plumber Certification Joseph Sellefeuille 9793 12-16-2019 Print Name of Plumber License# Date I certify that(check all that apply): Xk have installed the submetering equipment listed above in accordance with accepted plumbing standards. I have installed one or more water closets not exceeding 1.6 gallons per flush. Determined that existing water closets do not exceed 1.6 gallons per flush. The plumbing permit issued by the city/town,if required,is attached. (]Dwelling unit is connected directly to a meter installed by a water company and,in accordance with M.G.L.c.186,§22(p),does not require the installation of a submeter. n Signed under the pains and penalties of perjury, f' 5' ture of Licensed Phhber Property Owner Certification ; I certify that:(1)7his 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 e.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 ofwater in this dwelling unit was installed by a`water company" i 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 cbarging of water and/or sewer service,and a copy of this certification fors;(6)That all information included on this certification is true and accurate to the best of my knowle:dge- Signed under the pains and penalties of pcgwy, Q pPrint Name of Owner Signature ofOwner Date The property has been transferred to owner above and the unit Received FEB 21 202 remains is carnnliamx with the issrrments of M.G.L.G l86 22 Date: b SOH: *THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SEWUMA' E .1 BOAR)G+= 4 MDPH-CSP Submcteing Foam,Rev 11.4-16 H -r`. ° am 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!%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 H hland Ave Unit aQ03— j3funybt irt h1dw-24 !Town: Salem MA Zi Code;01970 EQUOTA '1VT 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 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-tow flush water closets(collets)not to exceed 1 dr0 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 infamuation: Master Meter Flexible Axis Manufacturer Model# Licensed Phcmber Certification Joseph Hellefeuille 9793 12-16-2019 Print Name of Pl a fiber L iceose# 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 cityAowu,if requited,is attached. ❑Dwelling unit is connected directly to a meter mstailed 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 1 pains and penalties of pedtlry, 11�(AJ S' aturte of Licensed Pfumber 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 submctm ing law(MGL c.186,§22);(2)Ali showedm ads,faucets,and water closets in this dwelling unit are water conservation devices that meet the standards specified above;(3)The water submwer 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 orwater and/or server 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 peaalties of perjury, Tqk, ct - ��1f6 f D -0 �L Print Name of Owner Signature of Owner Date d The property has been transferred to owner above and the unit Received remains in cOmPliance with the requirements of M.G.L.c. 186 22 Date: b BOM FEB 2-1 202 "THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INMATiNG SUBMPTERttNG CITY OF SALEM MDPH-CSP Subrmtering 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.§22 and 105 CMR 410.000:Minimum Standards of Fitness far 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 Adams: 205 bland Ave Linit#UG2 24 Ci a own: Salem MA Zi Code:01970 EQUIPMENT INSTALLATION INFORMATION 105 CMR 410.000 requires the installation of water conservation devices prior to a dwelling unit becoming eligible for the imposition an tenants of a,charge for water and/or sewer.The devices must meet the following specifications: Showexheads with maximmn slow rate not to exceed 2 x gallons per minute(2.5 gpm) Faucets with maximum flow rate not to exceed 21te gallons per minute(22 gpm) Ukra-low flush water closets(toilets)not to exceed l dt10 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 simitaraccredited association. A licensed plumber must install the water closets and submetering equipment. Submewing equipment information: Master Meter Flexible AXIS Manuihcam Model# Licensed Plumber Certification Jaaeph BellefeWile 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 acc=ptef 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 requited,is attached. ❑Dwelling unit is connected directly to a meter installed by a water company and,in accordance with M.G.L.c-t86,§22(p),does not require the installation of a submeter. Signed under the pains and penalties of perjury, Siena Sienatusi of Licaised Plumber Property Owner Certification I certify that:(1)This dwelling unit is eligible for the imposition on the tenants of a charge for water and/or sewer usage in accordance with the water submetering law(MGL c.136,§22);(2)All showcrheadis,faucets,and water closets in this dwelling unit am water conservation devices that meet the standards specified above;(3)11=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,§22; (4)The water meter or submeter measures the water usage=;elusive to this unit;(5)l will provide to the tenants of this dwelling unit,prior to o=upancy,a written rental agreement that clearly provides for the separate charging of water and/or sewer se viee,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. Signal under the pains and penalties of perjury, -� CL 0 t& kz-& Print Name of Own Si mature ofOwner D Date Tbc property has been transfetted to owner above and the unit Received remains in compliance with the requiremetiiis of M.G.L.c. t 22 Date: by BOH: *THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBMETERING CITY OF SALEM MDPH-CSP Submetering Form,Pcv 11.4-16 BOARD OF HEALTH MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH SUBMETERING OF WATER AND SEWER CERTIFICATION FORJW 'In accordance with M.G.L.c.186,§22 and lay CMR 410.000.Minimum Standards of Fitness for Human Habitation (State Sanitary Cade Chapter M the Hollowing dwelling unit is eligible for the imposition an the tenants or a charge for water and/or sewer service. PROPERTY INFORMATION Address: 205 H hland Ave _ M m minim in bug 24 Ci /Tows Salem MA N Code:01970 EQUIPM ENT 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 hallowing specifications: Showerheads with maximum flow rate not to exceed 2 x Fallon per minute(2.5 gpm) Faucets with maximum flow rate not to exceed 2 m gallons per minute(22 gpm) Ultra-low flush water closets(toilets)net to exceed 1 a►►a 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 Wo&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 Phrmher Cerdfleation - - Joseph Bellefeuille 9793 _ 12-16-2019 Print Name of Plumber License#- Date Irectify that(check all that apply): I 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 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.196,§22(p),does not require the installation of a submeter. Signed under the pains and penalties of perjury, Sisrxcature of Licensed Pffimber Property Owner Certification I certiiY that:(1)This dwelling unit is eligible for the imposition on the tenants of a charge for water and/or sewer usage in acoatdancc with the water submetering law(MGL c. 186,§22);(2)All showerhe a4 faucets,and wake closets in this dwelling unit arc water conservation devices that meet the standards specified above:(3)Ile water submeter measuring 1 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 ptovides for the separate charging of water and/or sewer service,and a copy of this certification fwnr,(6)That all information included on this certification is true and accurate to the bast of my knowledge. Signed under the pains and penalties of penury, rr /! 0 Lt-4,- Print Name of Owner Sivmature of Owner Date E3 The property has beentransfemd to owner above and the unit Received rtfrtains in cam Ba rre with the uirements of M.G.L:c. 186 22 Date: h BOHFEB 'THIS FORM MUST BE FILED MATH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBMETERING CITY OF SALEM MDPH-CSP Submeiering Form,Rev 11-4-16 BOARD OF HEALTH MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH SUBMETERI NG OF WATER AND SEWER CERTIFICATION FORM "In accordance with M.G.L.c.186.§22 and 105 CMR 410.000:Minimum Standards of Fitness for Human Habitation (State Sanitary Code Chapter 11),the following dwelling unit is eligible for the imposition on the tenants of a charge for water and/or sewer service. PROPERTY INFORMATION FA&�=.- 205` hland Ave 108 24 wn: Salem MA zi Code:019T0 EQoIP19=INSTALLATION IngFORhfATION 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/ar sewer.The devices must meet the following specifications: Sbowerheads 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) Ultra-tow flush water closets(toilets)not to exceed 1 6'r0 gallons per flash(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 Worlm Association or similar accredited association. A licensed plumber must install the water closets and submetering equipment. Subnetering equipment information: RI aster Meter Flexible Axis Manufacturer Model# Licensed Plumber CerfAcation dasaph Bellefetlille 9793 12-16-2019 i Print Name of Plumber — License# Date I certify that(chock all that apply): I have installed the submetering equipment fisted above in accordance with accepted plumbing standards. I have installed one or mote water closets not exceeding 1.6 gallons per fuusb. 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 instaAed by a water company and,in accordance with M.G.L.c.186,§22(p).does not require the installation of a submeter. Signed under the pains and penalties of perjury, Signature of Licensed Phrmber Property Owner Cadfication I certify that(1)This dwelling unit is eligible for the imposition on the tenants ofa charge for water mullor sewer usage in accordance with the water subtnetering law(MGL c.186,§22);(2)All showeAcads,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)TMe water meter or submcter 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 providers 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. Siped'uinder the pains and penalties ofpcdury, y -�g Ct KCr �Lit- t6 Art nt Name of Owner Sienature of Qwner Date LCL37bcrpmperty has been transferred to owner above and the unit Received liana with the requirementsofM.G.L a l86 22 Date: b EolE6 212020*THRM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBMETERING CITY OF SALEM MDPH-CSP Subntetering Form,Rev 11 4-16 BOARD OF HEALTH MASSACHU_SETTS DEPARTMIENT 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 fallowing dwelling unit is eligible for the imposition on the teaaaq of a charge for water and/or sewer service. PROPERTY INFORMATION Address: 205 Highland Ave Una AV? nf linift in hid,24 ' ff own: S819M MA Zip Code:01970 EQU1PIAM INSTALLATION INFORMATION 105 CMR 410.000 requires the installation of water conservation devices prior to a dwelling unit becoming eligible for the imposition on tcasnts of a charge for water and/or sewer.'Iba devices must moot the allowing specifications: Showexheads with maximum flow rate not to exceed 2 u�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(taflets)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 information: Master Meter Flexible Axis Manufachuer Model g Licensed Phwiber Certification JnmaAnh ellefeuiile 9793 12-16-2019 Print Name of Plumber License# Date I certify that(check all that apply): M 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 cityRown,if requh d,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 nfLiccnsed Ptmber 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 submutering 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 ofwater in this dwelling unit was installed by a`water company" as defined in M.G.L.c.186,§22; (4)'I be water meter or submeter measures the water usage exclusive to this unit;(5)I will provide to the tenants of this dwelling unit,prig 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, �5 lk— 1 Print Name of Owner Siolature of Owner Date The property has been transferred to owner above and the unit I�i` FEB 21 20 re nains in compliance with the mqaknLents of M.G.L.e. 186 22 Date: by BOH: *THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SU FYN9ALEM MDPH-CSPSubmcteriag F BOARD OF HEALTH otm,ttcv i t-4-lti 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 Fhaess far Human Habitation (State Sanitary Code Chapter M the following dwelling unit is eligible for the imposition on the tenants ofa charge far water and/or sewer service. PROPERTY JNFORMATION Address: 205 Highland Ave Lzose M§106 24 cir ffawa: Salem MA ZiR Code:01970 EQQIP1V PM INSTALLATION MORMATION 105 CIV R 410.000 requites the installation of water conservation devices prior to a dwelling unit becoming eligible far the imposition on tenants ofa charge forwater andlorsewer.The devices must meet the fallowing specificatim: Showerheads with maximum flow rate not to exceed 2 m fallons per minute(2.5 gpm) Faucets with maximum flow rate not to exceed 2 n gallons per minute(2.2 gpm) Ultra tow flush water closets(toilets)not to exceed 1 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 accuracy and testing of the American Water Wotks Association or similar accredited association. A Iiceased plumber must install the water closets and submetering equipment Submetering equipment information: 'IVaSter Meter Flexible Axis Menufacturer Model# Licenser!Plumber Certification Jowph eellefeuille 9793 12-16-2019 Print Name of Plumber License# pate t certi 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 Husk The plumbing permit issued by the cityhown,if required,is attached. ❑Dwelling unit is connected directly to a meat installed by a water company and,in accordance with M.G.L.c.196,§22(p),does not require the installation of a submeter. Signed under the pains and penalties of perjury, n SApartht ofLicensedPhanber Property Owner Certiflcation I certify that:(1)This dwelling unit is eligible for the imposition on the tenants ofa charge far 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 otwater in this dwelling unit was installed by a"rater company" as defined in M.G.L.c. 186,j 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 paints and penalties ofpctjury, v- .-L aS A uj- 4r 2 lc Print Name o Owner Signature of Owner Date 17 The property has been transferred to owner above and the unit Receiv remains in compliance with the is or KG.L,c.196 22 Date: b Bo 6 1 2020 *THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INMATING 5rg%JNG MDPH-CSP Submetcring Foray,Rav 11-4-16 BOARD OF HEALTH MASSACEfUSETTS 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 lI),the fadlowiog dwelling unit is eligible for the imposition on the tenants of a charge for water and/orsewer service. PROPERTY INFORMATION Address: 205 Highland-Ave "no105 #JUL nnift in h1der 24 Ci fI'own: Salem MA Zi Code;01970 105 CMR 410.000 EQUIP11�IIz 4T INSTALLATION IlY FORMATION 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: 5howmbeada with maximum flow rate not to exceed 2%,gallons per minute W gpm) Faucets with maximum flow rate not to exceed 2 gallons per minute(2.2 Spin) Ultmlow flush water closets(toilets)not to exceed l afe gallons per flush(1.6 gpf) The submetering equipment used to measure the quantity of water used for each dwelling unit and connnon 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. Subg equipment information: Master Meter Flexible Axis Manus Model# Liceased Plumber Cer ancatfon Joseph 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 Bush. Determined that existing water closets do not exceed 1.6 gallons per Bush. The plumbing permit issued by the cityAown,ifrequired,is attached ❑Dwelling trait is connected directly to a meter installed by a water company and,nit accordance with M.G.L.c.196,§22(p),does not require the installation of a submeter. Signed under the pains and penalties of perjury, ` f Si tune of Licensed lgtiQiber 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 submctoring 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 subrneter measuring the use of water,in the dwelling unit was installed by a licensed plumber and is in eompliauce 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 mcasures the water usage exclusive to this unit;(g)I will provide to the tenants of this dwclldng unit,prior to occupancy,a written rental agreement that clearly p is unitdcs 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 pals and penalties of pee jury, 0 Print Name o Owner Si lure of Owner D Date The property has been transfem W to owner above and the unit Received rcniains is liance with the uirements 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-CSF SuboicteringForin,Rev 11-4-16 BOARD OF HEALTH MASSACHUSETPS DEPARThIENT OF PUBLIC HEALTH SUBMETERING 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 U),the following dwelling unit is eligible for the imposition on the'wna;.t3 of a charge for water and/or sewer service. PROPERTY INFORMATION Address: 205 HWhiand Ave Linit AIN 24 Ci R'own: Salem MA Zip Code:01970 EQUIP1ZNT 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: Showedwads with maximum flow rate not to exceed 2 K allons per minute CLS gpm) Faucets with maximum flow rate not to exceed 2 gai[ons per minute(2 2 gpm) Ultra-law flush water closets(Whets)not to exceed 1 dro 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 Manufacturer _ Model# Lice>aud Plumber Certification Jowph Beilefeuille 9793 12-16-2019 _ Print Name of Plumber License# T Date I carolfy that(check all that apply)- MI have installed the submatering equipment listed above in accordance with accepted plumbing standards. ' I have installed one or more water closets not exceeding 1.6 gallons per flush. Determined that existing water closets do not exceed 1.6 gallons per flush. The plumbing permit issued by the city/town,if required,is attached Dwelling unit is connected directly to a meter installed by a water company and.in accordance with M.G.L.c. 186,§22(p),does not require the installation of a submeter. Signed under the pains and penalties of perjury, Slpmatuifi of License01mber _ Property Owner Ceriitltatlan 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`rater company" as defined in M.G.L,c.186,122; (4)The water meter or submeler measures the water usugc 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 �ofpeduty, 0 t /, t"ct,a c�l . ,.�4.(z. Cam/' 1 �Z! ( �' Print Name of Owner Simiature of Owner � a � D Date The property has been transferred to owner above and the unit Received ruing m�a:7 �lian�e wi►rt the sitemerrls of M.G.L �. 1�6 22 Date: by BoH•FEB 212012 *THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBMETERING CITY OF SALEM MDPH-CSP SubmeteringForm,Rcv 11.4-16 BOARD OF HEALTH MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH SUBMETERING OF WATER AND SEWER CERTIFICATION FORM tin accordance with M.G.I..c.186,§22 and 105 CMR 410.000.Minimum Standards of Fitness for Human Habitation (State Sanitary Code Chapter Ii),the f0flowing 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 umi t5103 24 frown: Salem MA zip code:01970 EQ1 PM IM--INSTALLATION INFORMATION 105 CMt 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 hollowing specifications: Sbowerheads with maximum flow rate not to exceed 2 x gallons per minute(2.5 gpm) Faucets with maximum flaw rate not to exceed 2'no gallons per minute(2.2 gpm) Ultra-low flush water closets(toilets)not to exceed 16,10 gallons per flush(1.6 gpt) The submetering equipment used to rneannw 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. Submctering equipment information: Master Meter Flexible Axis Manufacturer Model# I.lc•eased Plumber Certification Jaseph Bellefetsille__ 9793 12-18 2019 Print Name ofPlumber License 0 Date I certify that(check all that apply): IThehave 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. 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 require the installation of a submeter. Signed under the pains and penalties of perjury, 7 Sianature of Licens Plumber _ Property Owner Certification I certify that:(1)This dwelling unit is eligible for the imposition an the tenants of a charge fcr water and/or sewer usage in accordance with the water submetrring law(MOL c.186,§22),(2)All showenccads,faucets,and water closets in this dwelling unit ere water conservation devices that meet the standards specified above;(3)The water submeter measuring the use of water in the dwelling wait 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 urdt was installed by a"water company" as defined in M.G.L.c. 106,122, (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 an this eettification is titre and accurate to the best of my knowledge. Signed under the pains and pmalttiics of perjury, tt Print Name of Owner Sienatute of Owner iy Date E3 The property has been transferred to owner above and the unit Received remains 1n compliance with the rrowirements of M.G.L.c. 196 §22 Date: by Bott FEB 2 1 20 0 *THIS FORM MUST BE FILED WITH THE LOCAL.BOARD OF HEALTH PRIOR TO INITIATING SUBMETERING CITY OF SALEM MDPH-CSPSubenetetbgFomi Rev 114-16 BOARD OF HEALTH MASSACRUSETTS DEPARTMENT OF PUBLIC HEALTH SUBNWMRING OF WATER AND SEWER CERTIFICATION FORM "ln accordance with M.G.L.c.1$6,§22 and 105 CMR 410.000:Minimum Standards of Fitness far Hum=Habitation (State Sanitary Code Chapter Il f, water and/or sewer service. the following dwelling unit is eiigible for the imposition an the tenants of a charge for PROPERTY MFORMA17ON Address: 205 fthland Ave Wt g102 24 City/Town: Salem MA Zip Code:01970 EQU>Pi aVT INSTALLATLON INFORMAATION 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.Tbc devices must meet the following specification: Sbowerbeads with maximum flow rate not to exceed 2:ialloos 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 l `vca 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 Wotks Association or similar accredited association. A Iicensed plumber must install the water closets and submetering equipment. Submetering equipment information: Master Meter Flexible Axis Manufacturer Model# Licensed Plumber Certtilcadon Joseph Sellefeuille 9793 12-16-2019 Print Name of Plumber License# Date l certify that(check all that apply): l 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 requirt.d,is attached ❑Dwelling unit is connected directly to a meta 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, , —,_L�` IV Siximide of Licensed Phmtnber Property Owner Certilleadoe 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 taw(MGL c. 186,§22);(2)All showerireads,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.106,122, (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 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 ttvc and accurate to the best of my knowledge. S' ed under the pains and penalties of perjury, / a3 � 2!(6 lid Print Name of Owner Simmahn a ofnwner a D Date 0 The property has been transferred to owner above and the unit Received remains in complinace with the M9nirements of M.G.L c. 186 22 Date: by$OH: FEB 21 202 'THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INMATING SUBMETERING CITY OF SALEM MDPH-CSP SubmtoingForm,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 4I0.000.Minimum Standards of Fitness for Hum2n Habitation (State Sanitary Code Chapter a the following dwelling unit is eligible for the imposition our the tenants of a charge for water and/or sewer service. PROPERTY INFORMATION Adduxss: 205 Highland-Ave 101 a crown: Salem MA zip Code:01970 EQUEPMENT INSTALLATION INFORMATION 105 CMR 410.000 requires the installation of water conservation devices prier to a dwelling unit becoming eligible for the imposition ou tenants of a charge for water and/or sewer.The devices must meet the following specifications: Showerheads with maximum flow rate not to exceed 216 gallons per minute(2.s gpm) Faucets with maximum flow rate not to exceed 2 gallons per minute(2.2 spin) Ultra-low flush water closets(toilets)not to exceed t sn0 gallons per flush(t.6 gpo 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 Wailes Association or similar accredited association. A licensed plumber must install the water closets and submetaing equipment. Submctering equipment information: Masten'Meter Flexible Axis Manufacturer Model# Licensed Plumber Certlileadom dtxseph Betlefeuille__ 9793 12-16-2019 Print Name of Phumba— Utcanse#� - — 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 requhvd,is attached ❑Dwelling unit is connected directly to a meter installed by a water company and,is 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, c1 _-.- -- _ Sigmatutc7orlicensed 11furriber Property Owner CertiBeailon 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 subtnetering law(MGL c. 196,§22);(2)All showerheeds,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 runt.was installed by a"water company" as defined in M.G.L.c. t86,§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 ngm@mant 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 tree and accurate to the best of my lmowiedgru. Signed under the pains and penalties ofperjury, r,,,� 4S ; - ,.�- rt u"" � l fir Print Name of Owner Signature of Owner a Date O The pm"has been transferred to owner above and the unit Received ranains in cairnliance with the Mokeramts of M.G.L.e.186 22 Date: by BOH•FEB 21 202 *THIS FORM MUST BE FILED 1MTH THE i.ML BOARD OF HEALTH PRIOR TO INITIATING SUBMHTERING CITY OF SALEM MDPH-CSPSubmctering Form,Rev 11.4-16 BOARD OF HEALTH