Water submeter certificates - Units in the 6s 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 Humus 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 ser;m
PROPERTY IfNFORMA770M
Address: 4 First Street unit a6308 Of 11nitsdu hid,, 24
ci nown: Salem MA Zi Code•01970
EQUIPMENT INSTALLATION INFORMATION
105 CMR 410.000 requires the installation of water conservation devices prier to a dwelling unit becoming eligible far the
imposition on tenants of a.charge farwater and/or sewer.The devices must meet the following specifications:
Showetbeads with maximum flow rate not to exceed 24 gallons per minute(2.5 gpm)
Faucets with maximum flow rate not to exceed 2 gallons per minute(2.2 gpm)
Ultra-taw flush water closets(toilets)not to exceed 1 e+ca 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
Submdc&g equipment information: Master Meter Flexible Axis
Manufacturer Model#
Licensed Plumber Cert ffcatlon
Joseph Belle#euille _ 9793_ 12-16-2019
Print Name ofPhuuber 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.
'Me plumbing permit issued by the cityAown,if required,is attached.
[]Dwelling unit is connected directly to a meter installed by a water company and,in accordance with
M.G.L.c.186,§22(p),does not require the installation of a submeter.
Signed under the pains and penalties of pexj ury, &04 0- L LA41-4t
—- Si mature otticensed 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 submetcring law(Iv',GL 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 submetex measuring
the use of water in the dwelling unit was installed by a licensed plumber and is in oompliaacc with the standards
specified above,or the water meter measuring the use of water in this dwelling unit was installed by a"�watex 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 ofwaterand/or sewer service,and a copy of this certification form;(6)That all information included on
this certification is true and accurate to the beg of my knowledge.
Signed under the pains and penalties ofperjury,
(3- 2s i-Q dt weer
Print Name orOwner, Siesnature ofOwner I V D
Date
The property has bccn ttans&ved to owner above and the unit Rae
remains in corn liance with the uirements of M.G.L.a 186 22 Date: 9aH:e EB 21202
*THIS FORM MUST BE FILED WITH TIME LOCAL BOARD OF HEALTH PRIOR TO INITIATING OF SffF1:RiSALEM
MDPH-CSP SubrmteringForm,Rw 11-4-16 BOARD OF HEALTH
MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH
SUBMETERING OF WATER AND SEWER CERTIFICATION FORM
*In accordance will►M.G.L.a 186,§22 and 105 CMR 410.000:Minimum Standards of Fitness for Human Habitation
(State Sanitary Code Chapter II),the following dwelling unit is eligible for the imposition on the tenants of a charge for
water and/or sewer service.
PROPERTY INFORMATION
Addtess: 4 First Street iloit 1306 24
Citvribwa: Salem MA Zip Code:01970
EQUIPMENT INSTALLATION INFORMATION
105 CMR 410.000 requires the installation of water conservation devices prior to a dwelling unit becoming eligible for the
imposition on tenants of a charge for water and/or sewer.The devices must meet the following specifications:
Sbowerheads with maximum flow rate not to exceed 2 UAlons per minute(2.5 gpm)
Faucets with maximum flow rate not to exceed 2 gallons per minute(22$pm)
Ultra-low flush water closets(toilets)not to exceed 1 scxo 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 simileraccredited association.
A licensed plumber must install the water closets and submetering equipment
Submetering equipment information: Master Meter Flexible Axis
Manufacturar Model 0
Licensed Plumber CertMentlon
Joseph Belle#euiile 9793 1_2-16-2019
Print Name of Plumber^ License# Date
FfI
that(check all that apply):
e installed the submetering equipment listed above in accordance with accepted plumbing standards.ve installed one or more water closets not exceeding 1.6 gallons per flush.
ermined that existing water closets do not exceed 1.6 gallons per flush.
e plumbing permit issued by the cityltown,if te"ited,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, & , f k
_ _v Si tore o1rLicensed 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 submctcring 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 ofwater 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 trader the pains and penalties of perjury,
Print Name of Owner Sit±nature of Owner tto
D
te
The property lots been transferred m owner above and the unit eived FEB 21 20 0
remains in con Hance with the uirements of M.G.L.c.186 22 Date: BOH:
*THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INMATING SU�OF SALEM
MDPH-CSP Sub mictering Form,Rev 114-16 BOARD OF HEALTH
MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH
SUBM1iTERING 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 Ffabitation
(State Sanitary Code Chapter I1),the following dwelling unit is eligible for the imposition an the tenants of a chap for
water and/or sewer service.
PROPERTY INFORMATION
Address: 4 First Street 110it 4305 it Ofmoots in hid, 24
City/Town: Salem MA MCode:01970
EQUIPMENT INSTALLATION INFORMATION
105 C IVIR 410.000 require;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 fallowing specifications:
Stmwerheads with maximum flow rate not to exceed 2 4gallons per minute(2.5 gpm)
Faucets with maximum flow rate not to exceed 2 gallons per minute(22 gpm)
Ultra-low Bush water closets(toilets)not to exceed i'*'o gallons per flush(1.6 Wo
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 Made]g
Licensed Plumber Certification
Jaseptt Bellefeullie 97V3 12-16-2019
Print Name of Plumber License 0 Date
I certify that(check all that apply):
(MI have installed the submetering equipment listed above in accordance with accepted plumbing standards.
I have installed one or 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 ofa submeter.
Signed under the pains and penalties of perjury,
S' tute of Licensed Plumber
Property Owner Certification
I 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 subuu:tering 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)71e 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 tenennts of this dwelling unit,prior to occupancy,a written rental agreement that clearly provides for the
separate charging of water and/or sewer service,and a copy of this certification form;(6)That all information included on
this certification is true and accurate to the best of my knowledge.
Signed under the pains and penalties of perjury.
7. a. Tar 0l ` l
Print Name of Owner Si alum of Owner
Date
The property has been transferred to owner above and the unit Received
remains in coMpliance with the rcquirernents of M.G.L.c. 186 422 Date: by BOH:FEB 21202
*THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SiJj3
1 NJlriv�el�ALEM
MDPH-CSP Submetering Form,Rev 11.4-16 BOARD OFHEALTH
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
(Slate Sanitary Code Chapter II),the following dwelling unit is eligible for the imposition an the tenants of a charge for
water aodlor sewer service.
PROPERTY INFORMATION
Address: 4 First StrW 04 24
City/Town; Salem MA Zi Code:01970
EQUEP EXT 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 2:0lons per minute W 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*10 gallons per flush(1-6 gpf)
The submetering equipment used to measure the quantity of wafter used for each dwelling unit and common area must
meet the standards of accuracy and testing of the American Water Works Association or similaraccredited association.
A licensed plumber must install the water closets and submetering equipment.
Submetering equipment information: Master Meter Flexible Axis
Manuflcturer Model#
Licensed Plumber Crrdficatfan
Joseph Bellefeyille 9793 12-16-2019
Print Name of Plumber License# Date
I certify That(chock ail that apply):
PI have installed the submetWmg 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.
a
Signed under the pains and penalties of perjury, & e,
IV Si tune of Licensed Plimber
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 treasuring
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 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 perjury,
at 4 Z- - 1N' - k2 A&, C
Print Name of Owner Si Lure of Owner t D
Date
la The property has been transferred to owner above and the unit Received
terrains in Brace with The mquirements of M.G.L.c. 186 in Date: 1 by 80H: FEB 21 20
$THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SLIIIMETERING
CITY OF SALEM
MDPH-CSP Subnrcuxing Form,R,av 11.4-16 BOARD OF HEALTH
MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH
SUBMETERiMG OF WATER AND SEWER CERTIFICATION FORM
'In accordance with M.G.L.c.186,§22 and 105 CMR 410.000:Minimum Standatdt of Fitness for Human Habitation
(State Sanitary Code Chapter I),the following dwelling unit is eligible for the imposition on the tenants of a charge for
:eater and/or sewer service.
PROPERTY INFORMATION t
Address: 4 First Street twit#6303 24
Ciryfrown: Salem MA Zi Code:01970
EQ1UIPMZNT INSTALLATION INFORMATION
105 CMR 410.000 requires the installation of water conservation devices prig to a dwelling unit becoming eligible for the
imposition on tenants oEs 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 t 6t'0 gallons per flush(1.6 gpt)
The submetering equipment used to measure the quantity of water used far each dwelling unit and common area must
meet the standards or accuracy cad 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 FlaxiWe A)ds
Manufacturer y Model0
Lieensat Plumber Certlilcation
Jowph 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.
i ;The
Determined that existing water closets do not exceed 1.6 gallons per flush.
plumbing permit issued by the cityftown,if required,is attached.
0 Dwelling unit is connected directly to a meter installed by a water company and.in accordance with
M.G.L.c.186,§22(p),does not require the installation of a submeter.
Signed under the pains and penalties of perjury, k!
IV Si of LicensegPlumber
Property Owner Certlfieation
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 sboweAcads,faucets,and water closets in this
dwelling unit arc water conservation devices that meet the standards specified above;(3)The water submeler 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 rental agreement that clearly provides for the
separate charging orwater and/or sewer service,and a copy of ibis certification form;(6)That all information included on
this certification is tine and accurate to the best of my knowledge.
Signed under the pains and penalties of perjury,
Print Name of Owner Signature of Owner
Date
The property has been t ansf xted to owner above and the unit Received
rtrstains in omrsF lianc a with the mquirements of M.G.L.c. 186 22 Date: by Rom FEB 21 202
8THIS FORM MUST BE FILED WiTH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBMETERING
CITY OF SALEM
MOPH-CSFSubmatetingFann,R,av t1-446 BOARD OF HEALTH
MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH
SUBMETERING OF WATER AND SEWER CERTIFICATION FORM
*In accordance with M.G.L.a 126,§22 and 105 CMR 410.000:Minimum Standards of Frtoess for Human Habitation
(State Sanitary Code Chapter II),the Eollowing dwelling unit is eligible for the imposition on the tenants of a charge for
water and/or sewer service:.
PROPERTY INFORMATION
Address: 4 First Street unit 6208 Nnfurtift in h1dy 24
' mown: Salem MA z' Code:01970
EQ1111%Q14T INSTALLATION INFORMATION
105 CMR 410.Wo 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 foliowiag specifications:
Showerhe:ads with maximum flow rate not to exceed 2 u gallons per minute(2.5 gpm)
Faucets with maximum Dow rate not to exceed 2 2n gallons per minute(2.2 gpm)
Ultm4ow flush water closets(toilets)not to exceed I d10 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 Americas 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 Phrmber Certification
Joseph Beilefeuilie 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,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 submete r.
r
Signed under the pains and penalties of perjury, s.<
jPF
Si cure or Licensed Plumber
Property Owner CertMeation
1 certify that:(1)This dwelling unit is cGgible for the imposition on the tenants of a charge for water and/or sewer usage
in accordance with the water submetering low(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 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 truc and accurate to the best of my knowledge:.
Signed under the pains and penalties ofpe duty,
Qs f
Print Name of Owner Signature of Owner
AV Date
O The property has been transferred to owner above and the unit Rexeiv
remains in compliance;with the requirements of M.G.L.c. 186 22 Date: b Bo;:l-EB 21 202
*THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBMETIERING
CITY OF SALEM
MDPH-CSP Submetering Fotm,Rev 114-16 BOARD OF HEALTH
MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH
SUBMETERING OF WATER AND SEWER CERTIFICATION FORM
"In accordance with M.G.L.a 186,§22 and 105 CMR 410.000:Mmimum Standards of Fitness far Human Habitation
(State Sanitary Code Chapter ED,the 6nUowing dwelling unit is eligible for the imposition oru the tenants of a charge For
water andlarsewer service.
PROPERTY INb'QRItaIATION -
Fs: 4 Flrst Streetnit 6207 24
awa Salem MA Zi Code:01970
EQUEMEM INSTALLp XION INFORMATION
105 CMR 410.000 requires the installation of water conservation devices prior to a dwelling unit becoming eligible for the
imposition on tenants oft charge for water and/or sewer.The devices must meet the fbllowiag specifications:
56mverhaads with maximum flow rate not to exceed 2 4gallons 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 6'10 gallons per flush(1.6 gpf)
The submeteing 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 submetaing equipment.
Submetering equipment information: Master Meter Flexible Axis
manufacturer Model#
Licensed Phmber Cerdflcadon
. eph 8ellefeuille 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 Bush.
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, A r C 91, A
- Signaturc 6T Licensed Rdinber
Property Owner CertfIIeadlon
I certify that;(1)This dwelling unit is eligible for the imposition on the tenants ofa charge far water andlor sewer usage
in accordance with the water submetaring law(MGL c.186,§22);(2)All showencoads,faucets,and water closets in this
dwelling unit are water conservation devices drat 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 mans»ring the use of water in this dwelling unit was installed by a"water company„
as defined in M.G.L,c.186,§22; (4)"Me water meter or submeter me mores the water usage exclusive 10 this unit;(5)I
will provide to the tenants of this dwelling unit,prior to occupancy,a written tartar agreement that clear;y provides far the
separate charging of water and/or sewer service,and a copy of this certification fame;(6)That all information included on
this certification is true and accurate to the best of my knowledge-
Signed under thc pains and penalties ofperjuuy,
(?-A- (9
Print Name of Owner Sismture of Owner
Date
13 Ile property has been transferred to owner above and the unit Received
remains is So Bar a with the uirements of M.G.L,a 186 22 Date: by BOIL: FEB 21 202
'THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INMATING SUBMEfER NG
CITY - SALEM
MDPH-CSP Submctering Farm,Rev 11-4-16 BOARD OF HEALTH
MASSACIRUSETTS DEPARTMENT OF PUBLIC HEALTH
SUBMiE MRING OF WATER AND SEWER CERTIFICATION FORK
*In accordance with M.G.L.c.186,§22 and 105 CMR 410.000:Mini-n-Standards of Fitoess for Human Habitation
(State Sanitary Code Chapter II),the Blowing dwelling unit is eligible for the imposition on the tenants of a charge for
water and/or sewer service.
PROPERTY INFORMATION
Address: 4 First Street thift,4206 N of ignim in hiriv 24
c► f'own Salem MA zi Code:01970
EQUIPMENT INSTALLATION E FORMACTION
105 CMR 410.000 requires the installation of water conservation devices prior to a dwelling unit becoming eligible for the
imposition on tenants of a charge for water and/or sewer.The devices must meet the following specifications:
Showerheads with maximum flow rate not to exceed 2 x 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(toilets)not to exceed l 6'10 gallons per Bush(1.6 gpl)
The submetering equipment used to measure the quantity of water used for each dwelling unit and common area must
meet the standards of accuracy and testing of the American Water Works Association or similaraceredited association.
A licensed plumber must install the water closets and submetering equipment.
Submetering equipment i0brrrnation: master Meter FleAble Axis
manufacturer Model#
Licensed Plumber Certification
Joseph Sellefeuilis 9793 12-16-2019
Print Name of Plumber License 0 Date
I certify that(check all that apply):
[RI have installed the submetering equipment listed above in accordance with accepted plumbing standards.
I have bastalled 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 pcduty,
Signature of Licensed Pthrnber
Property Owner Certl0cation
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 accords=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
speci fled above,or the water meter measuring the use of water in this dwelling unit was installed by a'*ater 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 fnrn;(6)That all information included on
this certification is true and accurate to the best of my knowledge.
Signed under the pains and penalties of perjury,
Print Name of Owner Signature of Owner 131,&FMM
Date
0 The property has been transferred to owner above and the unit Received
remains in compliance with the uirem nts of M.G.L.c. 186 §22 Date: bx BOH: FEB 21 20 0
*THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUSMEtERING
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.1116,§22 and 105 CMR 410.000.Minimum Standards of Fa ness for Human Habitation
(State Sanitary Code Chapter IU),the following dwelling unit is eligible for the imposition on the tenaat9 of a charge for
.eater and/or sewer service._
PROPERTY INFORMATION -
Address: 4 First Street unit 6205 24
Ci /Iowa: 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 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 2 x�allons per minute(2.5 gpm)
Faucets with maximum flow rate not to exceed 2 gallons per minute(22 Spin)
Ultra-Iow flush water closets(toilets)not to exceed 1 d"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 similaraccredited association.
A licensed plumber must install the water closets and submetering equipment.
Submeteting equipment information: _ Master Metes' Flexible Axis
Manufacturer J T Model#
Licensed Plumber Certification
Joseph Beliefeutlle 9793 12-16-2019
Print Name of Plumber --V —W 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.
0 Dwelling unit is connected directly to a meter installed by a water company and,in accordance with
M.G.E..c.186,§22(p),does not require the installation ofa submeter.
Signed under the pains and penalties of pctjury,
Sivuture of Licensed Plumber
Property Owner CertMeation
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 submetaing law(MGL c. 186,§22);(2)All showencCads,faucets,and water closets in this
dwelling unit am water conservation devices that meet the standards specified above;(3)The water submeter measuring
the use of water in the dwelling 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 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 tho pains and penalties of pedury, y�
Print Name of Owner Sienature of Owner `—
bate
C3 The property has been trans&cred to owner above and tine unit Receiv�EB 212020
remains in cam Bocce with the reanirements of M.G.L.ra 18G§22 Date: b HOtI
'THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SC 3METE [�RLEM
MDPH-CSP Submctedng Fomr,Rev t 1-4-I6 BOARD OFF HEALTH
MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH
SUBMETERING OF WATER AND SEWER CERTIFICATION FORM
`In accordance with M.G.L.c.196,§22 and 105 CMR 410.000:Minimum Standards of Fitness for Human Habitation
(State Sanitary Code Chapter II),the following dwelling unit is eligible for the imposition on the tenants of a charge for
water and/or sewer service.
PROPERTY INFORMATION
Address: 4 First Street Lbu 6204 24
Ci rrown: Salem MA zi Code•01970
EQUIPMXNl'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 fallowing specifications:
Showerbeads with maximum flow rate not to exceed 2"gallons per minute(2.5 gpm)
Faucets with maximum flow rate not to exceed 2 gallons per minute(2.2 gpm)
Ultra-low,flush water closets(toilets)not to exceed I erro gallons per flesh(1.6 gpf)
The submetering equipment used to measure the quantity of water used for each dwelling unit and common area mast
meet the stands*of accuracy and testing of the American Water Worts 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 Cert3lie ation
Joseph Bellefeuille 9793 12-18 2019
Print Name of Plumber License it 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 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 cityhown,if required,is attached.
❑Dwelling unit is connected directly to a meter installed by a water company and,is 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,
suzzinnik orLicensed Plumber
Property Owner Certification.
I certify 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 subtaettxing law(MGL c.186,§22);(2)All showeiheads,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 s"water compatuy"
as defined in M.G.L.c.186,5 22; (4)The water meter or submeta 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 agrecmeat that clearly pmvidcs 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 say knowledge:.
Signed under the pains and penalties of perjury,
Q -V— 21 - p
Print Name of Owner Siosturc of Owner
Date 171
C3 The property his been transferred to owner above and the unit Received
remains in compliance with the uirements of M.G_L.c. 186 n Date: b BOH:FEB 21 202
*THIS FORM MUST BE FILED 141TH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SL TffIIG.
LEM
MDFH-CSP Subnrcteriag 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 far Humus Habitation
(State Sanitary Code Chapter II),the following dwelling unit is eligible for the imposition on the tenants of a charge for
water and/orsewer service.
PROPERTY INFORMATION
Address: 4 First Street tin t jy 6203 24
Ci R'own: S81em MA Zip Code:01970
EQUIPMENT INSTALLATION INFORMATION
10S 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�tlons per minute(2.5 gpm)
Faucets with maximum flow rate not to exceed 2 gallons per minute(2.2 gpm)
UUra-low flush water clostt(toilets)not to exceed 16'10 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 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 Model#
Licensed Plumber Certification
Joseph Beliefeuille 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 flush.
The plumbing permit issued by the cityAovi%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 ofa submeter.
Signed under the pains and penalties of perjury,
AV Si lure oltUcensed Plumber
Property Owner Certification
I certify that:(1)This dwelling unit is eligible for the imposition on the tenants of a charge for water and/or sewer usage
in accordance with the water submetering law(MGL c.186,§22);(2)All showerheads,faucets,and water closets in this
dwelling unit are water conservation devices that meet the standards specified above;(3)The water submeter measuring
the use of water in the dwelling unit was installed by a licensed plumber and is in compliance with the standards
specified above,or the water meter measuring the use of water in this dwelling unit was installed by a`water company"
as defined in KG&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 orwater and/or sewer service,and a copy of this certification form;(6)That all information included on
this certification is true and accurate to the best of my knowledge.
Signed under the pains and penalties ofperjury,
ems-4 AS, -
Print Name of Owner Sinature of Owner
Tb
te
°The property Isar been transferred to owner above and the unit eived FEB 21 20 0
remains in con Hance with the nirements of M.G.L.c. 196,422 Date: BOH:
*THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIORTO INITIATING SUE&"KALEM
MDPH-CBP Subrttctering Farm,Rev 11-4-16
BOARD OF HEALTH
MASSACHUSETTS DEPARTMMNT 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 WFORMAIION
Address: 4 First Street vnit b6202 Qriinih h1dor 24
Ci bwn: Salem MA Zi Code:01970
EQUVMENT 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:
Showetheads 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)
Ulha-tow Suss water doh(toilets)not to exceed l&10 gallons per flush(1.6 gpQ
The submgtering equipment used to measure the quantity ofwater used for each dwelling unit and common area must
meet the standards of accuracy and testing of the American Water Works Association or similar accredited association.
A licensed plumber must install the water closets and submete ring equipment.
Submetering equipment information: Master Rueter Flexible Ails
Manufacturer Model#
Licensed Plttmber Cert'lflcatioo
Joseph Sellefeuille 9793 12-1 fi-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 cityhowa,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,§22(p),does not require the installation of a submeter.
Signed under the gn pains and penalties of perjury,
v SiwnaftiFe of Licensed P ber
Property Owner Certification
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 submatering 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 aunt was installed by a licensed phunber 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 written renal 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 pejury,
Print Name of Owner Signature of Owner —
Date
The pr%c*has beca transferred to owner above and the unit Received
remains in compliance with the requirements of M.G.L.c 186 22 Date: by BOH.FEB 21 202
*THIS FORM MUST BE FILED WRH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING S CIMET�Rji�ALEM
MDPH-CSPSubmetecing 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 than, Habitation
(State Sanitary Code Chapter II),the following dwelling unit is eligible for the imposition on the tenants of a charge for
water and/orsewer,rvice.
PROPERTY INFORMATION
Address: 4 First Street nit 6201 Qfunift in itide,24
cityfrown: Salem MA Zi Code:01970
EQ1J11%MNT 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 following specifications:
Sbowerheads With maximum flow rate not to exceed 2:jallons per minute(2.5 spin)
Faucets with maximum flow rate not to exceed 2 gallons per minute(2.2 am)
Ultra-low flush water closets(toilets)not to exceed 100 gallons per flush(1.6 gpQ
The submatering equipment used to measure the quantity of water used for each dwelling unit and common area must
meet the standards of accuracy and testing of the American Water Worsts Association or similar accredited association.
A licensed plumber must install the water closets and submetering equipment.
Submetering equipment information: luster Meter Fie)ible Axis
Manufacturer Model#
Licensed Phimmber Certification
.9vseph 8e11eieuille 9793 12-16 2019
Print Name of Plumber License# Date
Mr 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 perWt 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,§22(p),does not require the installation of a submeter.
Signed under the pains and penalties of perjury,
S' fora of Licensed Plumber
Property Owner Cerdfimilon
I certify that:(1)This dwelling unit is eligible for the imposition on the tenants of a charge for water and/or sewer usage
in accordance.with the water submetering law(MGL c.186,§22);(2)All showerheads,faucets,and water closets in this
dwelling unit are water conservation devices that meet the standards specified above;(3)The water submeter measuring
the use of water in the dwelling unit was installed by a licensed plumber and is in compliance with the standards
specified above,or the water meter measuring the use of water in this dwelling unit was installed by a"water company"
as defined in M.G.L.c.186,122; (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 tb occupancy,a written rental agreement that clearly provide for the
separate charging of water and/or sewer service,and a copy of this certification force;(6)That all information included on
this certification is true and accurate to the best of my knowledge.
Signed under the pains and penalties of perjury,
Print Name of Owner Sit3rature of Owner
13 Date
The property has becn transferred to owner above and the unit �i"`dFEB 21 202 remains in liartc c with the ants of M.G.L e. 186 22 Date: b BOH:
"THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING St&NRMLEM
MDPH-CSPSubmetecing 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 CtAR 410.000.-Minimum Standards of Fitness for Human Habitation
(State Sanitary Code Chapter 1n,the following dwelling unit is eligible for the imposition on the tenants of a charge for
water and/or sewer service.
PROPERIT INFORMATION
Address: 4 First Street i boa#61108 X j0f unitm irk bLdL 24
C' rrowu: Salem MA zi Code:01970
EQUIPMENT INSTALLATION INFORMATION
105 CMR 410.000 requires the installation of water conservation devices prise to a dwelling unit becoming eligible for the
imposition on tenants of a charge for water andlar sewer.The devices must meet the following specifications:
Sbowerheads with maximum flow rate not to exceed 2 54 gallons per minute(L5 gpm)
Faucets with maximum flow rate not to exceed 2 2M gallons per minute(22 gpm)
Ultra-tow Bush water closets(toilets)not to exceed 1 6"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 submetaing equipment.
Submetering equipment iaforatation: master Meter Flexible Axis
-- --- . Manufacturer Model#
Licensed Plumber Certification
Joseph Beiiefeuille _ 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 cityAown,if required,is attached.
❑Dwelling unit is connected directly to a met=installed by a water company and,in accordance with
M.G.L.c.186,§22(p).does not require the installation of a submeter.
Signed under the pains and penalties of perjury, n
Si¢rrature of Licens lumber
Property Owner Certification f
I certify that:(1)This dwelling unit is eligible tar the imposition on the tenants of a charge far water and/or sewer usage
in accordance with the water subumtering 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;(3')I
will provide to the tenants of this dwelling unit,prior to occupancy,a written rental agreement that clearly provides for the
separate charging of water and/or sewer service,and a copy of this certification form;(6)That all information included on
this certification is true and accurate to the best of my knowledge.
Signed under the pains and penalties of perjury,
Print Name of Owner Si Lure ofOwner
Date
O The property has been transferred do owner above and the unit Received r14as in •liance with the uirements of M.G.L.c.186 FEB 21 20 22 Date: b HOB:
*THIS FORM MUST BE FILED 1MTH THE LOCAL BOARD OF HEALTH PRIOR TO IN1TIAliNG SUF(gMALG'vl
MDPH-CS?Subractering Form,Rev 11-4-16 BOARD OF HEi.L-i;i
MASSACHUSETFS DEPARTMENT OF PUBLIC HEALTH
SUBMETERINO 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 tmants of a charge for
water and/or sewer services
PROPERTY INFORMATION _ -
Address: 4 First Street iinU g6107 24
City/Town: Salem MA zi Code:01970
EQUlPly ENT 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 ofa charge for water and/or sewer.The devices must meet the fallowing speciScatioos:
Sbowerheads with maximum flow rate not to exceed 2*4 gallons per minute(2.S gpm)
Fauccis with maximum flow rate not to exceed 2 gallons per minute(2.2 gpm)
Ultra-low flush water closets(toilets)not to eacccd 1 61°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.
Submetexfng equipment information: faster Meter Flexible Axis
Manufacturer Model#
Lieessed Phrmber CertMeitton
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 flush.
Determined that existing water closets do not exceed 1.6 gallons per flush.
The plumbing permit issued by the cityAown,if required,is attached.
❑Dwelling unit is connected direcdy 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 oft submetet:
Signed under the pains and penalties of perjury, � n
Sietaatum of 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 accordanncx with the water submetering law(MGL c.186,§22);(2)All showerheads,faucets,and water closets in this
dwelling unit are water conservation devices that meet the standards specified above;(3)The water submeter measuring
the use of water in the dwelling unit was installed by a licensed plumber and is in compliance with the standards
specified above,or the water meter measuring the use of water in this dwelling unit was installed by a"water company"
as defined in M.G.L.c. 186,§22; (4)The water meter or submeter measures the water usage exclusive to this unit;(5)I
wilt 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.
Signed under the pains and penalties of perjury,
t J�V- _ zltj6 diet
Print Name of Owner ture of Owner D
Date
D The property has been transfeaed to owner above and the unit Received
restrains in compliance with the rcouire ments of M.G.L.c. 186 22 Date -by HOH:
'THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUIIM@TERING
CITY OF SALEM
MDPH-CSP Submetering Form,Ptev 114-16 BOARD OF HEALTH
MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTS
SUBMETERING OF WATER AND SEWER CERTIFICATION FORM
*In accordance with M.G.L,c.186,§22 and 105 CMR410.0N.Minimum Standards ofFnaess farlitrt Habitation
(State Sanitary Code Chapter ITj,the fallawi0 dwelling unit is eligible far the imposition on the tenants of a clorge for
water and/or sewer service.
= PROPERTY INh'031MATTON —� ---_
FA�ddrmess: First Street 6106 Salem MA �i Code:01970
0.000 EQUIP M3CNTINSTALLATIONINFORMATION
requires the installation of waterconservation devices prior to a dwelling unit becoming eligible for the
tenants of a charge far water and/or sewer.The devices must meet the fallowing specifications.
Showerbeads with maximum now 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 Hirsh water closets(toilets)not to exceed l b1°gallons per flush(L6 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 submetrting equipment.
Submetudng equipment information: Master Meter Flexible Axis
Manufacturer Model,#
Licensed Number Certification
dt�aeph Belle—ferrule - 9793 12-16 2019
Print Name of Phurnber -- — License# Date
I certify that(check all that apply):
RMI 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 eityRown,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 submjeter.
Signed under the pains and penalties of perjury,
simatuit of Licensed PGMar
Property Owner Certification
I certify that:(1)This dwelling unit is a ible for the imposition on the tenants of a charge for water and/or sewer usage
in accordance with the water submctermg law(MGL c.186,§22);(2)All showenccads,faucets,and water closets in this
dwelling unit are water conservation devices that most 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 cleady 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 pairs and penalties ofpajuty,
Print Name of Owner Signature of Owner H D
Date
The property has been transfetrad to owner above and lire unit dived FEB 2120 0
remains is Bare r with the is of M.G.L.a 186 22 Date: h BOH:
*THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INMATING SUB�y�7����y
MDPH•CSP Subraetering Form,Rev I1-4-16 BOACi_RD Ora HE
MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH
SUBMETERI<NG OF WATER AND SEWER CERTIFICATION FORM
'In accordance with M.G.L.a 186,§22 and 105 CMR 410.000:Minimum Standards of Fitness for Hamm Habitation
(State Sanitary Code Chapter 11),the following dwelling unit is eligible for the imposition an the tenants of a charge for
water and/orsewer service.
PROPERTY INFORMATION
Address: 4 First Street uni,g6105 24
Citv/Town: Salem MA Zip Code•01970
EQUIPMENT INSTALLATION INFORMATION
105 C MR 410.000 requires the installation of water conservation devices prior to a dwelling unit becoming eligible for the
imposition on tenants of a charge far water and/or sewer.The devices must meet the following specifications:
Sbowerheads with maximum flow rate not to exceed 2 Aloes per minute(2.5 gpm)
Faucets with maximum flow rate not to exceed 2 gallons per minute(2.2 gpm) y
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 standards of accuracy and testing of the American Water Works Association or sim►i1ar accredited association,
A licensed plumber must install the water closets and submetering equipment.
Submetering equipment information: Master Meter Flexible Axis
Manufacturer Model#
!Acensed Plumber CertiElcadon
Joseph Bellefettiile 9793 12-16-2019
Print Name of Plumber License# 4 ` Date
I certify that(check all that apply):
t�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 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 submete r.
Signed under the pains and penalties of pcdury,
Si tune of Licensed lumber
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 submctcring law(MGL c.186,§22);(2)All showerlx:ads,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 licenser/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`wvater 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,prier 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 fbrm;(6)That all information included on
this certification is true and accurate to the best of my knowledge:.
Signed under the pains and enalties of perjury,
�•�— Ib /file
Print Name of Owner Si elute of Owner
Date
C3 The property has been transferred to owner above and tic unit Received
remains in con liance with the requirements of M.G.L.e:.186 22 Date: I by BOH: FEB 21 20 0
"THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBMETERI NG
CITY OF SALE-'A
MDPH-CSP Submetering Form,Rev 114-16 BOARD OF HEAL i-li
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 forHurmn Habitation
(State Sanitary Code Chapter 1I),the fallowing dwelling unit is eligible for the imposition on the tenants of a charge far
water and/or sewer service.
^ I PROPERTY INFORMATION 7
Address: 4 First Street 11na 6104 �;-, i, 24 a
Ci -mown: Salem KA Zip Code:01970
EQUIPIbmm INSTALLATION INFORMATION 1
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:
Sbowetheads with maximum flow rate not to exceed 2 me gallons per minute(2.5 gpm)
Faucets with maximum flow rate not to exceed 2'n gallons per minute(22 gpm)
Ultra-low flush water closets(toilets)not to exceed 1 6"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 Icensed plumber must install the water closets and submetering equipment.
Submetering equipment information: _ Master Meter Flexible Axis
Manufacturer _ Model#
!Jcensed Plumber Certification
Joseph Bellefeuille 9793 12-16-2019
Print Name of Plumber -- Ucense# - Date
I certify tbat(check all that apply):
I have installed the submetering equipment listed above in accordance with accepted plumbing standards.
1 have installed ate 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 canceled 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, &X40- t—
Signatum6fLicersed lumber
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 submstcring law(MGL c.186.§22);(2)All showahcads,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 rental agreement that clearly provides for the
separate charging orwater and/or sewer service,and a copy of this certification foma;(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,
Print Name of Owner Signature of Owner
Date
13 The property has been transferred to owner above and the unit Received
remains in compliance with the muirements of M.G.I.c. 186 22 Date: BOH: EB 212020
*THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO iNmA nNG SllBMETpp�
CITY OF5LEM
MDPH-CSP Subuetering 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 R),the following dwelling unit is eligible for the imposition on the tenants of a charge for
water aed/orsewer aervice.
PROPERTY INFORMATION
Address: 4 First Street trnf, 6103 in h1da 24
city/Town: Salem MA ZIP Code:01970
EQUIPMM IINSTALLATION INFORMATION
105 CMR 410.OW requires the installation of water conservation devices prior to a dwelfing unit becoming eligible for the
imposition on tenants of a charge for water and/or sewer.The devices must meet the following speci8catioas:
Sbowedwads 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 s'1°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 simiilm accredited association.
A licensed plumber must install the water closets and submetering equipment.
Submetering equipment information: Master Meter Flexible Axis
Mamufacturer Model#
Licensed Plumber CertiScatlon
Joseph Bellefeuille 9793 12-16 2019
Print Name of plumber License# Bate
I certit�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 flursb.
Determined that existing water closets do not exceed 1.6 gallons per flusb.
The plumbing pecaut issued by the cityhown,ifrequired,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 tinder the pains and penalties of perjury,
awwwre oiLicensed Phmber
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 showenccad;,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 plunnbcr 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;(57i 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 fntm;(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 a t -P- -0 Z!(` t
Print Name of Owner Si sacra of Owner D
Date
1]'Me property has been transt'eced to owner above and the unit Received
remains in compliance with the requirements of M.G.L.c.186 V2 Date: s. nr%u.PEB 21 202
"THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBMETERING
CITY OF SALEM
MDPH-CSP Submetering Form,Rev I14-16 BOARD OF HEALTH
MASSACRUSETTS DEPARTMENT OF PUBLIC HEALTH
SUBMETERING OF WATER AND SEWER CERTIFICATION FORM
"In accordance with M.G.L.c.186,§22 and 105 CMR 410.000:Minimum Standards of Fitness for Human Habitation
(State Sanitary Code Chapter II),the following dwelling unit is eligible for the imposition on the tenants of a charge for
water andtorsuwer service.
-- PROPERTY INFORMATION
Address: 4 Flrst Street unat 6102 24
City/Town: Salem MA Zi Code:01970
EQUIPbUNT 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:
Sbvwerheads with maximum flow rate not to exceed 2 x gallons per minute(2.5 gpm)
Faucets with maximum flow rate not to exceed 2 Zn gallons per minute(2.2 gpm)
Ultra-low flush water closets(toilets)not to exceed 16110 gallons per flush(1.6 gpf)
The submetering equipment used to measure the quantity of water used for each dweftg unit and common aren 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 equipment.
Submetering equipment information: Master Meter Flexible Axis
Manufacturer Model 0
Licensed Phrmber Certificadon
Jweph Bellefeuiile 9793 12-11;2019
Print Name of Plumber License# Date
I certify that(check all that apply):
I have installed the submetering equipment fisted above in accordance with accepted plumbing standasds.
r I have installed one or more water closets not exceeding 1.6 gallons per flush.
fl Determined that existing water closets do not exceed 1.6 gallons per flush.
The plumbing permit issued by the cityhown,if required,is attached.
El 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 sad penalties of perjury, n
Surnafure ofLicenscdPlumber
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 showerbceds,faucets,and water closets in this
dwelling unit are water conservation devices that meet the standards specified above;(3)The water submrter 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 sewer service,and a copy of this certification fours;(6)That all Information included on
this c ertiFcation is true and accurate to the best of my knowledge.
Signed trader the pains and penalties of p«jury,
Ata.--as
Print Name of Owner SiEmatrue of Owner r,D
Fb
te
WEIVM
O The property has beers transfetsed to owner above and the unit ceived
remains in cam lianc a with the uirements of M.G.L,c. l 22 Date: SOH: '_ 9, 1 7n 0
*THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBMETERING
CITY OF SALEM
MDPH-CSP Submetering Farm,Rcv 114-16 BOARD OF HEALTH
NEASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH
SUBMETERING OF WATER AND SEWER CERTIFICATION FORM
*In accordance with M.G.L.c.1.96,§n and 105 CMR 410.000:Minimum Standards of Fitness for Human Habitation
(State Sanitary Code Chapter 11),the following dwelling unit is eligible for the imposition on the tenants of a charge for
water and/or sewer service.
PROPERTY INFORMATION
Address: 4 First Street umf#6101 24
C' frown: Salem MA ZI Code:01970
EQUIPMIKNT 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 forwater and/or sewer.The devices must meet the following specifications:
Showerheads with maximum flow rate not to exceed 2""gallons per minute(LS 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 dw 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 simiiaraccredited association.
A licensed plumber must install the water closets and submetering equipment.
Submetering equipment information: Master Meter Flexible Axis
Mamu&cmm Model#
Liceased Plumber Cerdfleation
Joseph Bellefoullle 9793 12-16-2019
Print Name of Plumber License# Date
I certify►that(check all that apply):
I have installed the submetcring equipment listed above in accordance with accepted plumbing standards.
I have installed one or more water closets not exceeding 1.6 gallons per flush.
Determined that existing water closets do not exceed 1.6 gallons per flush.
The plumbing permit issued by the cityftown,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, 014
-,
v bignaturedrucensed Mumber
Property Owner Certlacadon
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 subractering law(MGL c.186,§22);(2)All showerheads,faucets,and water closets in this
dwelling unit are water conservation devices that meet the standards specified above;(3)The water submeter measuring
the use of water in the dwelling unit was installed by a licensed plumber and is in compliance with the standards
specified above,or the water meter measuring the use of water in this dwelling unit was installed by a"water company"
as defined in M.G.L.c.186.§22; (4)The water meter or submeter measures the water usage exclusive to this unit;(5)I
will provide to the tenants of this dwelling unit,prior to occupancy,a written rental agreement that clearly provides for the
separate charging of water and/or sewer service,and a copy of this certification form;(6)That all information Included on
this certification is titre and accurate to the best of my lotowledge.
Signed under the pains and penalties of perjury,
Print Name of Owner Sismature of Owner
Date
0 The property has been transf ved to owner above and the unit Received FEB 21 20
remains in compliance with the requirements of M.G.L.a 186 22 Date: b SOH:
*THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUN T RI SALEM
M13PH-CSP Submetering Form,Rev I1.4-16 BOARD
OF HEALTH
MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH
SUBiVIETERItYG OF WATER AND SEWER CERTIFICATION FORM
*In accordance with M.G.L.c.1116.§22 and 105 CMR 410.000:Minimum Standards of Fitness for Human Habitation
(State Sanitary Code Chapter II),the fallowing dwelling unit is eligible far the imposition an the tenants of a charge for
water and/or sewer service. _
PROPERTY INFORMATION
Address: 4 First Street o ;t#6008
c frown: Salem- MA Zip Code:01970
EQUIPIVIEW UMALLATION 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 fallowing specifications:
Showerheads with maximum flow rate not to exceed 2 UAlons per minute(2.5 gpm)
Faucets with maximum flow rate not to exceed 2 gallons per minute(2.2 gpm)
Uk a-low flush water closets(toilets)not to exceed l Wo 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.
Submetaring equipment information: _ Master Meter Flexible Axis
Manufacturer Model#
J Licensed Plumber Certification
_ Jowptt Beilefeuille 9793 _ 12-16-2019
Print Name of Plumber License# Date
Mir I certify that(check all that apply):
installed the submatering equipment listed above in accordance with accepted plumbing standards.
g,have
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.
E]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, ` .
IV Sionature of Licensed Phunber
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 submclaring law(MGL c.186,§22k(2)All showerheads,faucets,and water closets in this
dwelling unit ate 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 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 ofpc jury, ff
A. A.
Print Name of Owner Siensture of Owner 17
Date
O The property has been transferred to owner above and the unit Received
remains in ca fiance with the rwuh=cnb of MG.L.c. 186 22 Date: by BOH: FEB 21 20 .0
*THIS FORM MUST BE FILED 1NTTH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBMETERING
CITY OF SAL"EEM
MDPH-CSPSubmctermg Form,Rev 11-4-16 BOARD OF HEALTH
MASSACRUSETTS DEPARTMENT OF PUBLIC HEALTH
SUBMETERING OF WATER AND SEWER CERTIFICATION FORM
*In accordance with M.G.I..e.186,§22 and 105 CMR 4I0.000:Minimum Standards of ids for Human Habitation
(State Sanitary Code Chapter I1),the following dwelling unit is eligible for the imposition on the tenants of a charge for
.rater and/ur sewer service.
PROPERTY INFORMATION j
Address. 4 FIrst Street I T.ft 46006 -jiabidp24
I cinyfPown: Salem-
MA zl Code:019T0
EQUIPMENT INSTALLATION INFORMATION
105 CMR 410.000 requires the installation of water conservation devices prim to a dwelling unit becoming eligible for We
imposition on tenants of a charge for water and/or sewer.The devices must meet the fattowiag specifications:
Showerbeads with maximum flow rate not to exceed 2 K gallons per minute(2.5 Spin)
Faucets with maximum flow fate not to exceed 2'!r gallons per minute(22 gpm)
Ultra-low flush water closets(toilets)not to exceed 1019 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 closem and submetering equipment.
Submetering equipment infinmation: Master Meter Flexible Axis
Manufacturer Model#
Licensed Phu nber Certification
Joseph Bellefeuiile 9793 12-16-2019
Print Now ofPhimber — License# Date
jI 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
fr M.G.L.c.186,§22(p),does not require the installation of a subtneter.
l Signed{ ga paitss and penalties of perjury,
- --Prop"Owner Certification
I certify that:(1)This dwelling unit is eligible ror 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 sbowenccads,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.186.5 22; (4)The water-meter or submeter measures the water usage exclusive to dais 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 five and accurate to the best of my knowledge.
Signed under the pains and penalties ofperjury, �-
ha
Print Name of Owner 13 signature of owner
tDate. S4
'ihe property has been transferred to owner above and the unit Received
ranains in cOMPliance with the Muftements of M.G.L.a 196,422 Date: b sOIFEB 2 12020
*THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBMETERING
CITY OF SALEM
MDPH-CSPSubmeteringForm,Rev 114-16 BOARD OF HEALTH
MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH
SUBMETERING OF WATER AND SEWER CERTIFICATION FORM
*In aceonl xnce with M.GL.c.186,§22 and 105 CMR 410.000:Minimum Standards of Fitness far Human Habitation
(State Sanitary Code Chapter II),the fallowing dwelling unit is eligible for the imposition on the tenants of a charge for
water and/or sewer service.
PROPERTY INFORMATION
Address: 4 First Street Unit o6W4. 24
Ci /Town: Salem MA Zi Code:Q197Q
EQ11WM NNT[INSTALLATION INFORMATION
105 CMR 410.000 requites the installation of water conservation devices prior to a dwelling unit becoming eligible far the
imposition on tenants of a charge for water and/or sewer.The devices must meet the following specifications:
Showerheads with maximum flow rate not to exceed 2%allons per minute(2.5 gpm)
Faucets with maximum flow cafe not to exceed 2 gallons per minute(2.2 gpm)
Uhm-low flush water closets(toilets)not to exceed 1 6'xa gallons per flush(1.6 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 Works Association or similar accredited association.
A licensed plumber must install the water closets and submetering equipment.
Submetering equipment information: Master Meter Flexible Axis
Manuilklu+er Model tie
Licensed Plumber Certification
Jwepli 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 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.L.c.186,§22(p),does not require the installation of a submeter.
Signed under the pains and penalties of perjury, 4 r'
Signature of Licensed Plumber
Property Owner Certification
t certify that:(I)Tbis dwelling unit is eligible for the imposition an the tenants of a charge for water and/or sewer usage
in accordance with the water submetm*law(MGL c.186,§22);(2)All showcnccads,faucets,and water closets in this
dwelling unit are water conservation devices that meet the standards specified above;(3)The water submeter measuring
the use of water in the dwelling unit was installed by a licensed plumber and is in compliance with the standards
specified above,or the water meter measuring the use of water in this dwelling unit was installed by a"water company"
as defined is M.G.L.c.186,§22; (4)The water meter or submeter measures the water usage exclusive to this unit;(3)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 am and accurate to the best of nay knowledge.
Signed under the pains and penalties of perjury,
r.-cl+-- a3 A5..i"C;., -;L 0
Z! b t
Print Name of Owner Sienature of Owner
Date
The property has been traosfea d to owner above and the unit Receive�
remains in Hance with the ahernents or M.G.L.c.186 22 Date: by BOHI-EB 21 2020
*THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SCITMAF IOLEM
MDPH-CSP SubnmeteringFarmx,Rev I14-16 BOARD OF HEALTH
MASSACHUSE77S DEPARTMENT OF PUBLIC 11EALTH
SUBMETERING OF WATER AND SEWER CERTIFICATION FORM
*In accordance with M.G.L.c.186,§22 and 105 CMR 410.000:Minimum Standards of Fitness for Human Habitation
(State Sanitary Code Chapter II),the following dwelling unit is eligible for the imposition on the tenants of a charge for
water and/or sewer service.
PROPERTY INFORMATION
Address: 4 First Street Hali 46002 24
/Town: Salem MA — Cex1e.01970
EQUi SM4TINSTALLATIONINFOtiMA'TION
105 CMR 410.000 requites the inswilation of water conservation devices prig 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:
Sbowerheads with maximum flow rate not to exceed 2�*#allons per minute(2.5 gpm)
1 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 s'�s 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 Works Association or similar accredited association.
A licensed plumber must install the water closets and submeteriug equipment.
Submetering equipment information: _ Minster Meter Flexible Axis
Manufacnuer _ Model# J
Licensed Plumber Certification
Jtaseph Beilefeuille 9793 12-16 2019
Print Name of Plumber License# Date 1
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 cityAown,if rcquired,is attached.
❑Dwelling unit is cotmected 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,
Styumire afUcensedPhnmber
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 showmimds,faucets,and water closets in this
dwelling unit ate water conservation devices that meet the standards specified above;(3)The water submcter measuring
the use of water in the dwelling unit was installed by u 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.186,122; (4)'Ibe 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 fans;(6)That all information included on
this certification is tree and accurate to the best of my knowledge.
Signed under the pains and penalties of perjury, j
�AmJ=as Ai,.+-- (1,,, Q—
Print Name ot Owner Si mature ofOwner D
Date
The property has been transfetred to owner above and the unit Received
remains in compliance with the aire:6ernts of M.G.L.a 186 22 Date: §jE1OHCrR
*THIS FORM MUST BE FiLED WITH THE LOCAL BOARD OF HEALTH PRIOR TO IitltTiATING SUB R N-d
CITY OF MDPH-CSP Submetering Form,Rev 11-4.16 BOA OF HEALTH