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Water submeter certificates - Units in the 7s MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH SUBMETERING OF WATER AND SEWER CERTIFICATION FORM *111 accordance with M.G.L.c.1116,§22 and 105 CMR 410.000:MWoaum Standards of Fitness for Human Habitation (State Sanitary Code Chapter II),the following dwelling unit is eligible for the imposition on the tenants ora charge for water and/or sewer service. PROPERTY INFORMATION Address: 4 First Street , . 24 C' frown: Salem MA ZiR Code:01970 EQUIPMENT 1NsT'ALLATION INFOEtMATiON 105 CM R 410.000 requires the installation of water conservation devices prig to a dwelling unit becoming eligible for the imposition on tenants of a charge for water and/or sewer.The devises must meet the fallowing specifications: Sbowalicads with maximum flow rate not to exceed 2 dons per minute(2.5 gpm) Faucets with maximum flow rate not to exceed 2 gallons per minute(2.2 gpte) Ultm-low flush water closets(toilets)not to exceed 100 gallons per flush(1.6 gpf) The submetering equipment used to measure the quantity of water used for each dwelling twit 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. Submeted;ng equipment infomuetion: Master deter Flexible Axis Mane Mortal# Liceused Plumber CerEi[kation Joseph Bellefeulile 9793 12-16-2019 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 standards. I have installed one or more water closets not exceeding 1.6 gallons per flush. Dt b=dned that existing water closets do not exceed 1.6 gallons per flush. The plumbing permit issued by the cityhown,ifrequhttl,is attached. Q Dwelling unit is connected directly to a meta installed by a water company and,in accordance with M.G.L.c.196.1 22(p),does not require the installation of a submeter. Signed under the pains and penalties of perjury, )A-f IVSignature of Licensed Plumber Prole orgy 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 iti 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 on this certification is tree and accurate to the best of my lmowledge. Signed under the pains and penalties of peijwy, Print Name or own Sionature of Owner 13 Date The property has been transfetred to owner above and the unit Received remains in con linace with the rcQuirements of MG.L.c. 186 §22 Date: hy Rn1 FE "THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO Ir4=TtNG SUBMETERING CITY OF MDPH-CSP Submeteting Foray Rev 114-16 BOARD HEALTH MASSACH1USETTS DEPARTMENT OF PUBLIC HEALTH SUBIKETERING OF WATER AND SEWER CERTIFICATION FORM *In accordance with M.G.L.c.196.6 22 and I05 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/orsewer rFl PROPERTY INFORMATION s. 4 First Street it 7 07 24 n: Salem MA Zi Code:01970 R 410.000 re EQ�'l4ENT INSTALLATION INFORMATION quires the installation of water conservation devices prig to a dwelling unit becoming eligible far the tion on tcaaats ofa charge forwater and/or sewer The devices must meet the following specifications: heads with maximtim flow rate trot to exceed 2 11ons per minute(25 gpm) with maximum flow rate not to exceed2 gallons per minute(2.2$pm) w flush water closets(toilets)not to exceed 1�°gallons per hush(1.6 gpf) metering equipment used to measure the quantity of water used for each dwelling unit and common area must e standards of accuracy and testing of the American Water Wodcs Association or similar accredited association. sed plumber must install the water closets and submetering equipment. Submetetiag equipment information: Master Meter Flexible Axis -- Manufacturer R Model# Lich Plumber Certification ---JI+ ph Bepefeujjle— _ 9793 12-16 2019 Print Name ofPhimber - —License# 4 —— 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 mom water closets not exceeding 1.6 gallons per push. Determined that existing water closets do not exceed 1.6 gallons per flush. 3 The plumbing permit issued by the cityAown,if required,is attached, ❑Dwelling unit is connected directly to a meter installed by a water company rind,in accordance with f M.G.L.c. 136.122(p),does not require the installation of submeter. LSilggned under the pains and penalties of perjury, Si tun o Licensed P Property Owner Certification ertify that:(1)This dwelling unit is eligible for the imposition on the tenants Ora charge fair waterand/orsewerusage accordance with the water submetering law(MGL c.186,§22);(2)Ali showerheads,faucets,and water closets in this dwelling unit am water conservation devices that meet the standards specified above;(3)The water subme�er measuring the use of water is 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 cantlmny„ as defined in M.G.L.c.186,§22; (�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 flan;(6)That all information included on this certification is true and accurate to the best of my Imowle dge:. Signed under the pains and penalties of perjury, Ur,� a-3 ?- Print Name of Owner i2nattire of Owner ❑The property has been transferrred to owner above and the unit bete Rrxeiv rem is /inner with the rrirements of M.G.L,Q 186 22 Date: b BO B 21202& *THIS FORM MUST BE FILED MM THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBMETERING CITY OF SALEM MDPH-CSP Sulimctering Form,Rev 114-16 BOARD OF HEALTH MSSAC] USETTS DEPARTMENT OF PUBLIC REALTE SUBMETERING OF WATER AND SEWER CERTIFICATION FORM "In accordance with M.G.L.c.186,§22 and 105 CN1R 410.00: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. FROPF.RTY fNP'01tMATiON Address: 4 First Street - 7306 24 0 ,mown: Salem MA ZiP Code:01970 105 C11dA 410.000 EQUUTA 4T INSTALLATION INFORMATION requires the installation of water conservation devices prior to a dwelling unit becoming eligible for the impositinn on tenants of a charge for water and/or sewer.The devices must meet the following specification: Show"beads with maximum flow rate not to exceed 2 x gallons per minute(2-5 gpm) Faucets with maximum How rate not to exceed 2 2110 gallons per minute(22 gpm) Ultra-low flush water closets(toilets)not to exceed 1 saw gallons per flush(1.6 gpf) The submetering equipment used to measure the quantity of water used for each dwelling unit and comma arcs must meet the standards of accuracy and testing of the American Witten Wozks Association or similar accredited association. A licensed plumber must install the water closets and submetering equipment. Submeetering equipment information: Master Meter Flexible Axis Manufatcturer — Model# Ucensed Plumber Certlticaldon Joseph Bellefetflite 9793 12-16 2019 Print Name of Plumber License# Date I eaft that(check ale that apply): I have installed the submetering equipment listed above in accordance with accepted plumbing standards, I have installed a=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,ifraquhY4 is attached. Dwelling unit is coupe cte d directly to a meter installed by a water company a ist accordance with M.G.L.c. 196,1 22(p),does not require the installation ofa submetex Signed under the pains and penalties of perjury, Si tore of Property Owner Certification Licensed Phmtbex 1 certify that:(1)Tluis dwelling unit is eligible for the imposition on the tenants ofa charge far water and/or sewer usage in accordance with the water submatering law(NIGL c.185,§22);(2)All showerhe ads,fatuxts,and water closets in this dwelling unit are:water conservation devices that meet the standards specified above;(3)The water submexer 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 submetex 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 ag=mcat 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 Irue Bud accurate to the best of my knowledge. Signed under the pains and penalties of perjury, Z-/(4 /Cc{ Print Name of Owner Signatttre of Owner Date The Properly has been ttxmsfanted to owner above and the unit Received re rnains in compliance with thr:r uirenrtensts of M.G.L,c. 186 22 Date: Bpi 'THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INMA71NG SUBM&jRjWGcw— CITY OF SALEM MDPH-CSP Subitteteeiat;Pam Rev i 14-16 BOARD OF HEALTH MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH SUBMETERING OF WATER AND SEWER CERTIFICATION FORM *In accordance with M.G.L.r-186,§22 and 105 CM 4I0.000.Minimum Standards of Fitness far Human Habitation (State Sanitary Code Chapter ED,the foiiowing dwelling unit is eligible for the er imposition an the tenants of a charge far water andlorsewer svice. PROPERTY FORMATION Address: 4 First Street it 7305arluti 24 Ci /Town: Salem MA Z' code:01970 105 CMR 410.000 RQIJIPlV1Te� WSTALLATION WFORUT ATION requires the installation of water conservation devices prior to a dwelling tent becoming eligible for the imposition on tenants of a charge for water and/or sewer.The devices must meet the fallowing specifications: Showcdieads with maximum now rate not to exceed 2'e allems per minute(2-5 gpm) Faucets with maximum flow into not to exceed 2 gallons per minute(2.2 gpm) Ultra-low flush water closets(toilets)not to exceed I W°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 infmtmatioa: Master Meter Flexible Axis Manufacturer Model# Liceau d Plumber Certification Jose h Beilefeuiile 9793 12-162019 Print Name of Phunber License# Date I certify that(check all that apply): I have installed the submetering equipment listed above in accordance with accepted plumbing standards. I have installed one or more water closets not exceeding 1.6 gallons per flush. Determined that existing water closets do not exceed 1.6 gallons per flush. The plumbing permit issued by the city/town,if required,is attached. []Dwelling unit is connected directly to a meter installed by a water company and,in accordance with M.G.L.c.186,§22(p),does not require the installation of a submeter. Signed under the pains and penalties of perjury, ? il Si fLiccnsed Plumber Property Owner Certification certify 1hat:--(1}7* gelling unit is eligible for the imposition on the tenants of a charge for water and/or sewer usage in accordance with&water submetcring law(MGL C.186,§22);(Z)All showerhe ads,faucets,and wales closets in this dwelling unit are water conservation devices that meet the standards specified above;(3)The water submater measuring the use of water in the dwelling unit was installed by a licensed plumber and is in compliance with the standards specified above,or the water meter measuring the use of water in this dwelling unit was installed by a"water company, as defined in M.G.L.c. 186,§22; (4)The water meter or submeter measures the water usage exclusive to this unit;(5)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, sw as A. �, Z ll6 lee Print Name of Owner SiMiture of Owner a D 13 Date The property has been transferred to owner above and the unit Received remains in compliance with the: g#cmenlS of M.G.L.C. 186 22 Date: gOH; "THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBMETERING CITY OF SALEM MDPIi-CSPSubmcteriogForm,ttev I l•4-I6 BOARD OF HEALTH MASSACHUSETTS DEPARTM ENT OF PUBLIC HEALTH SUBMXTERINO OF WATER AND SEWER CERTIFICATION FORM `10 aecaartance with M.G.L.c.186,§22 and 105 CMR 410.000:Minimum Standards of Fitness far Humus Habitation (State Sanitary Code Chapter Uj the following dwelling unit is eligible for the imposition on the tenants of a charge for water and/or sewer service. PROPERTY INFORMATION FAdd:rcss: 4 First Street 7304 24 Powa; Salem _ MA ZipCade:01970 idfl�'F'II1iSTAl:IXRON INFORMATION ATION 105 CMR 410.000 requires the installation of water conservation devices prior to a dwelling unit becoming eligible far the imposition an tenants of a charge far water and/or sewer.The devices must meet the fallowing specifications: Sbowerheads with maximum flaw rate not to exceed 2 x gallons per minute(2 5 gpm) Faucets with maximum flow rate not to exceed 2 gallons per minute(2.2 gpm) Ultra-;ow flush water closets(toilets)not to exceed 1 d"o gallons per Qenh(1.6 Spf) + The submetering equipment used to measure the quantity of water used for each dwe[Iing unit and common area must meet the standards of accuracy and testing of the Ametfcau Water Works Association or similaraceredited association. A licensed plumber must install the water closets and submetering equipment Submetering equipment information: Master Meter Flexible A)is Manufacturer Model ff ~� Licensed Piesmber Certification Joseph Beilefeulile 9793 12-16 2019 Print Name of Plumber ���� � I certify that(check all that apply): License# Date 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 push. Aetesmined 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 accordrtnee with M.G.L.c.186,§22(p),does not require the installation of a submeter. Signed under the pains and penalties of perjury, & -- 0- Si0MhjrPnf Licensed Plumber Property Owner CerMeation 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(MGL c.186,§22);(2)All showerheads,faucets,and water closets art this dwelling unit are wafer canscrvataan devices that meet the standards specified above;(3)7be water submeter measuring the use of water its the dwelling unit was installed by a licensed plumber and is in compliance with the standards specified above,or the water ttteter 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;(�I will pmvide to the tenants of this dwelling unit,prior to occupancy,a written rental agreement on separate charging of water and/or sewer service,and a copy of this Certification form;(6)That all information inchui that clearly provides for or the this certification is suer and accurate to the best of my knowledge. Signed under the AA pains and penalties of perjury, I , %Scs� �� a3 fit G f 7 �"' LL Print Name of Owner Si:rnature of Owner Data t1cwki V.I . The property has been ttansfctred to owner above and the unit Receiv tensains in come lianee wills the►eauirements of M.G.L.c. 186 22 Date: b HOI�r:EB 21 2020 HiS FORM MUST BE EILED WITH'fHE LOCAL BOARD F HEALTH PRIOR TO 1NITIAMNG SUBMETERING CITY OF SALEM MDPH-CSF SubrueterWs Form,Rev 11-4-16 BOARD OF HEALTH MMSACHUSE77S DEPARTNIENT OF PUBLIC HEALTE! SUBMETERING OF WATER AND SEWER CERTIFICATION FORM 1°In accordance with M.G.L.c.I96,§22 and 105 CMR 410.000.Minimum Standards of Fitness for Human Habitation (Stale Sanitary Code Chapter II),the following dwelling unit is eligible for the imposition on lbe tenants of a chap for water and/or sewer service. PROPERTY&FORMATIdDN Address: 4 First Street 24 0 mown: Sateen MA Zi Code:01970 EQUIPMENT INSTALLATION I1gFORl�;ATIOPT 105 CMR 410.0100 requires the installation of water conservation devices prior to a dwelling unit becoming eligible for the imposition on tenants of a charge for water and/or sewer.The devices must meet the fallowing specifications: Sbowetheads with maximum flow rate not to exceed 2'r gallons per minute(2.5 gpm) Faucets with maximum flow rate not to exceed 2?AQ gallons per minute(2.2 gpm) Ultra-tow flush water closets(toilets)not to exceed 1 6'10 gallons per flush(1.6 gpf) The submetering equipment used to measure the quantity of water used for each dwelling unit and common area must meet the standards of accuracy and testing of the American Water Works Association or similar accredited association. A Iicersed plumber must insWi the water closets and submetering equipment. Submetering equipment infoniration: Master Meter Flexible Axis Meaufacturer Model# Licensed Plumber Cerdf eRtfon 45mel? 8ellefeunle_`_ 9793_ 12-15-2019 Print Name of Plumber — - License# — fate 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,ifrequired,is zMched. ❑Dwelling unit is connected directly to a meter installed by a water company and,in accordance with M.G.L.c.186.1 22(p),does not require the installation of a submeler. Signed under the pains and penalties of perjury, --- SilmBttrte a LlCensel Phanber Property Owner Certification t certify that:(1)This dwelling unit is eligible for the imposition on the tenants of a charge for water ua Wor 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" f as defined in M.G.L.c.186,122; (4)The water meter or submeter measures trite wale usagc caclusive to this unit;(S)1 will provida to the tenants of this dwelling unit,prior to occupancy,a written rental agzeoment that clearly provides for the I 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 under the pains and penalties of perjury, " Q �W Print Name of Owner �Silgmnakmof Owner L' D The property has been transferred to owner above and the unit Date c. 186, .22 liana with the airemaents of M.G.L. Date: � rSERTs in conQ EB 21 2020 *THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING Suu RRING C�F SALEM MDPH-CSP SubmeteringFotmn,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 forNumaa Habitation (State Sanitary Code Chapter II),the following dwelling unit is eligible fbr the imposition an the tenant of a charge for water andforsewer service. PROPERTY 1NF'ORMAIION V:dro= First Street nit 7 01 24 Salem MA Zi Code:01970 10.0�0 EQUI]P'M ENT INSTALLAtON INFORI►iATION b�the installation of water conservation devices prig to a dwelling unit becoming eligible for the ntenants ofe<charge far water and/orsewer.The devices must meet the fallowing specifications: s with maximum flow rate not to exceed 2*gallons per minute(2.5 gpm) Faucets with maximum flow rate not to exceed 2 s'a gallons per minute(22 gpm) Ultra-low flush water closets(toilets)not to exceed 1 s"ao gallons per!lush(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 similaraccredited association. A licensed plumber must install the water closets and submetering equipment. Submetering equipment information: Master Meter Flexible Axis Manufacturer - Model# Licensed Plumber CertLfication - f Joseph Bellefeullle_ 9793 12-16-2019 Print Name of Plumber License# Date I cettiPY 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 push. Determined that existing water closets do not exceed 1.6 gallons per flush The plumbing permit issued by the cityltown,ifrequired,is attached. ❑Dwelling unit is connected directly to a teeter installed by a water company and,in accordance with M.G.L.c.186,§22(p),does not require the installation of a submeter. Signed under the pains and penalties of perjury, n a. Sienature of Lkens id Plumber /Property Owner Cerdlicadon l certify that:(1)This dwelling unit is eligible for the imposition on the tenants of u charge for water and/or sewer usage in accordance with the water satbmetering law(MGL c.186,§22);(2)All showerheads,faucets,and water closets in this dwelling unit are water conservation devices that meti the standards sp%ified above;(3)The water submaier 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 MG.L,c. 186,§22; (4)The vaster meter or submetcr measures the water usage exclusive ;to this unit (5)I will provide to the tenants of this dwelling unit,prior to occupancy,a written rental agreement that clearly provides for the separate charging of water and/or sewer service,and a copy of this certification form;(6)That all information included on this certification is true and accurate to the best of my knowledge. Signed under the pains and penalties of perjury, ax¢c t&A L Print Name of Owner Sismature of Owner --M7tt Date The property has been transferred to owner above and the unit remains in compliance with the reauirememts of M.G.L.a 186 22 Date: Received21 2020 *THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBMETERING CITY OF SALEM MDPH-CSP Submetetmg Form,ptv 11.4-16 BOARD OF HEALTH MASSACHUSETPS DEPARTMEENT OF PUBLIC REALTH SUBMETERING OF WATER AND SEWER CERTIgICATION FORM "In accordance with M.G.L.e.186,§22 and 105 CMR 410.000:Minimum Standards of Fitness for Humus Habitation (State Sanitary Code Chapter 1I),the following dwelling unit is eligible for the imposition on the tenants of a charge for water and/or sewer service, - PROPERTYINFORMATIONAdams: 4 First Street _^i �8 24 C' frown: Salem MA ern code:01970 105 CMR 410.000 EQ�vMEW INSTALLATION WFORMATION 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 foilowing speciEcadow: Sbowerheads with maximum flow rate not to exceed 2 x gallons per minute(2S gpm) Faucets with maximum flow rate not to exceed 2 m gallons per minute(22 gpm) [Mfrs-low flush water closets(toilets)not to exceed 1610 gallons per flesh(1.6 gpo The submetering equipment used to measure the quantity of water used for each dwelling unit and common area must astral the standards of accuracy and testing of the American Water Works Association or similaraceredited association [;; censed plumber must install the water closets and submetering equipment.metening equipment information: T Master Meter Flexible Aids Maaufatextuer -� _ Model# Llcenseti i°umber Certiiie ration .Ita�ph 8ellefeuille 9793 12-15 2_019, Print Name of Plumber ~ Date 1 certlfly that(check all that apply): I have installed the submetering equipment listed above in accordance with accepted plumbing standards. 1 have installed one or more water closets not exceeding 1.6 gallons per flush. Determined that existing water closets do not exceed 1.6 gallons per flush. The plumbing permit issuerd by the eityltown,if rexpfired,is attached. Dwelling unit is connected directly to a meter installed by a water company and,in accordance with M.G.L.c.136,122(p),does not require the installation ofa submcter. Signed under the pains and penalties of pc4my, M Si of Licensed 1'ltanber Property Owner Certification rdwelling that:(1)This dwelling unit is eligible for the imposition on the tenants of a charge far water and/or sewer usage ance with the water submetering law(MGL c.186,§22);(2)All showerheads,faucets,and water closets in this unit are water conservation devices that meet the standards specified above;(3)The water submeter measuting f water in the dwelling unit was installed by a licensed plumber and is in compliance with the standards specified above,or the water meter measuring the use of water in this dwelling unit was installed by a"water company" as defined in M.G.L.c. 186,122; (4)The water meter or submeter measures the water usage exclusive to this unit;(5)1 will provide to the tenants of this dwelling unit,prior to occupancy,a written rental agreement that clearly provides for the separate charging orwater and/or sewer service,and a copy of this certification force;(6)That all information included on this certification is taro and accurate to the best of my knowledge. Signed under the pains and penalties ofpcquM r asp � 1�1-�. t�J � �L&6— In !fPrin r re of Owner a Date The ptvpctiy has been transferred to owner above and the unit Received remains in wrrmlianee with the renuirem nits of M.G.L.a 186 22 Date: r} BE3y EB 2 *THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO IIa MAI ING SUBMETER114G CITY OF SALEM MDPH-CSPSubrmtetingForm,Rev 11-4-16 HEAL 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:Minirmim Standards of Fitness for Human Habitation (State Sanitary Code Chapter ln,the foIlowing dwcftg unit is eligible for the imposition an the tenants of a charge for water and/or sewer service. PROPERTY INFORMATION FAd&==: 4 First StreetTinit 7207 24 Pown: 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 an tenants of a charge for water and/or sewer.The devices must meet the foilowing spectFicatioas: Showerheads with maximum flow rate not to exceed 2gallons per minute(2.5 gpm) Faucets with maximum flow rate not to exceed 2 gallons per minute(2.2 Spin) Ultra-low flush water closets(toilets)not to exceed 161!0 gallons per flush(1.6 gpt) The submetering equipment used to measure the quantity of water used for each dwelling unit and common arcs must meet the standards of accuracy and testing of the American Water Wotks Association or similar accredited association. A licensed plumber must install the water closets and submetering equipment, Submetering equipment information: Master Meter Flexible Axis Manufacturer Model g Licensed Plumber Certification Joseph HeRefoullie 9793 12-18 2019 Ptint Name of Plumber - License# - — Date I certify that(chock 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 cityAown,if required,is attached ❑Dwelling unit is connected directly to a meter installed by a water company and,in accordance with XG.L.c. 186,§22(p),does not require the installation of a submeter. Signed under the prima and penalties ofperjcuy, Si m tore of Lic Phanber Property Owner Certification 1 certify that:(1)This dwelling unit is eligible for the imposition on the tenants of a charge for water and/or sewer usage in accordance with the water submetering law(MGL c.186.§22).(2)All showerhaads,faucets,and water closets in this dwelling unit are water conservation devices that meet the standards specified above;(3)The water submnter 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 agrcemcat that clearly provides for the separate charging of water and/or sewer service,and a copy of this certification fomn;(6)That all information includedon this certification is true and ac curnito to the best ofmy knowledge. Signed under the pains and penalties ofpcdury,A P e / z. Aq Print Name of Owner � Si store of Owner is t Date The property has been hansfetre d to owner above and the unit Received rrsnains in eomfliance with the r4ouirements of M.G.I..e. 186 22 Date: by$Ole: EEL 2 p *"PHIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBMETERING CITY OF SALEM MDPH-CSPSubmctc&g Form,ltevt1-4-t6 BOARD OFHEALTH -iJ MASSACHUSETTS DEPARTMENT OF PUBLIC IIEALT R SUBMETERING OF WATER AND SEWER CERTIFICATION FORM *fin accordance with M.G.L.c.186,§22 and 105 CUR 4I0.000:Minimum Standards of Fitness for Human Habitation (State Sanitary Code Chapter 13),the following dwelling unit is eligible for the imposition on the tenants of a charge for water and/or sewer service. -- - PROPERTY tNFt7RMAT`lON — , Add:: 4 First Streat 720$ 24 rCMR alem _ MA Zi Code:01970 .t100 DSQ�It�ENT INSTALLAT dlq INFORRfAInON requirees the installation of water conservation devices prior to a dwelling unit becoming eligible for the tenants ofe charge for water and/or sewer.Tile devices must meet the fallowing specifications: with maximum flow rate not to exceed 2 xallons per minute(2.5 gpm) aximum flow rate not to exceed 2=" gailans per minute(2,2 gpm) Ultra-low flush water closets(toilets)not to exceed I s'10 gallons per flush(1.6 gp0 The submetering equipment used to measure the quantity of water used for each dwelling unit and common area must meet the standards of accuracy and testing of the American Water Works Association or similaraccredited association. A licensed plumber must install the water closets and submetering equipment. Submeteriag equipment information: Master Meter Flexible AXIS Manufaci utx T-- Model# Uceused Plumper certification Jnanfth Beilefeuille- 9793__ _ '12-t6-2019 Nam Print Na of Plumber License# Date I certify that(check all that apply): I have installed the submetering equipment listed above in accordance with accepted plumbing standards. I have installed one or more water closets not exceeding 1.6 gallons per flush. Determined that existing water closets do not exceed 1.6 gallons per flush. The plumbing permit issued by the city/town,if required,is attached Dwelling unit is connected directly to a meter installed by a water company and,in accordance with M.G.L.c.186,§22(p),does not require the installation of a submeter. Signed under the pains and penalties of perjtny, l IL 7 - ---.--- Signa f icensod Phmtber 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 submctering law(MGL c.186,§22);(2)All showerhands,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 ureter measuring the use of water in this dwelling unit was installed by a"water company" as defined in NLG.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 far the separate charging of water and/or sewer service,and a copy of this certification foam;(6)That all informarion included on this certification is true and accurate to the best of my knowledge. Signed under the pains and penalties of perjury, 16 AS Print Hama of Owner Signature of Owner ;�-- Date The property has been tttansfen+ed to owner above and the unit Received retrains in compliance with the reanimments of M.G.L.c. 186,_�22 Date: 80 .— *THIS FORM MUST BE FILED W1TH THE LOCAL.BOARD OF HEALTH PRIOR TO INITIATING SUBM 1 MDPH-CSP Submetering Form,Rev 11-4-16 CITY OF SALEM BOARD OF HEALTH MASSACITUSETTS 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 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: 4 First Street [Tait AMOS #Of cinin in h1dix 24 _+J Citv/Town: Salem MA Zip Code:01970 } EQUIPMENT 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 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 21n gallons per minute(2.2 gpm) Ultra-low flush water closets(toilets)not to exceed 1 6'16 gallons per flush(1.6 gpf) The subrnetering equipment used to treasure the quantity of water used for each dwelling unit and common area must meet the standards of accuracy and testing of the American Wales Wodcs Association or similar accredited association. A licensed plumber must install the water closets and submetering equipmenL i Subowtering equipment information: Master Meter Flexible Axis _ Manufacturer Model# { Licensed Plumber Certtileatlon Joseph Beilefoullle 9793 12_-1.6-2019 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. I have installed one or more water closets not exceeding 1.6 gallons per flush. Determined that existing water closets do not exceed 1.6 gallons per flush. The plumbing permit issued by the city/town,if required,is attached. 0 Dwelling uric is connected directly to a meter installed by a water company and,in accordance with M.G.L.c.186,§22(p),does not requite the installation of a submeter. Signed under the pains and penalties of pcdury, n -- 5g! Sioatum 'f Licensed Plurrtber Property Owner Cuffleation 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 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 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)Ile 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 atrd/or sewer service,and a copy of this certification form;(6)That all information included on this certification is ttue and accurate to the best of my knowledge. Signed under the pains and penalties of perjury, a as }( .,CrN Print Name of Owner Signature of Owner Date The property has been transferred to owner above and the unit Date 2 12020 remains in corruliance with the rrnuirranents of M.G.L.c.196 §22 Date: *THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INIT1ATIN6"MffW@M BOARD OF HEALTH IviDPH-CSP Subrrtcicring Farm,[rev 11-4-16 MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH SUBMETERING OF WATER AND SEWER CERTIFICATION FORM *In accordance with M.G.L.c.186,§22 and 105 CMR 410.000:Minimum Standards of Fitness for Human Habitation (State Sanitary Code Chapter I),the following dwelling unit is eligible for the imposition on the truants ofa charge for :: water and/or sewer service. PROPERTY INFORMATION - FA 4 First Street � __sawt;7204, � o,„o;u:�hia�24 Ci frown: Salem MA Zi Code:01970 EQU1PbM4T INSTALLATION IXFORJ%ATION 105 CMR 410.000 requires the installation of water conservation devices prior to a dwelling unit becoming eligible far the imposition on tenants ofa charge far water and/or sewer.The devices must meet the fallowing specifications: Showcrhends with maximum flow rate not to exceed 2 x p1lons per minute(L5 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`r0 gallons per flush(1.6 gpf) The submetcring 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 Iicensed plumber must install the water closets and submetering equipment Submetering equipment information: Master Meter Flexible Axis Mwufacturer Model# Licensed Plumber Certification Joseph Bellefeuille _ 9793 12-16-2019 Print Name of Plumber License# Date I cernfy that(check all that apply): I have installed the submtetering 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 pre flush. The plumbing permit issued by the city/town,ifrequired,is attached. ❑Dwelling unit is connected directly to a meter installed by a water company and,in accordance with M.G.L.c. 1E6,§22(p),does not require the installation of a submeter. Signed under The pains and penalties of perjury, --I± h _ Signandi of Licensed lumber Property Owner Ceramcation I certify that:(1)This dwelling unit is eligible for the imposition on the tenants ofa charge for water and/or sewer usage in accom%=with the water subrmctering law(MGL c.186,§22);(2)All showerbcads,faucets,and water closets in this dwelling emit are water conservation devices that meet the standards specified above;(3)The water submeter measuring the use of water in Ilia 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 bya"water company" as defined in M.G.L.c.186,§22; (4)The water meter or submeter measrucs 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 pmvid=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 truc and accurate to the best of my knowledge. Signed under the pains and penalties of perjury, i to- r� �t k U�LL Z42 Print Name of©weer Signature of Owner H`— Date O The property has bean trams&rmd to owner above and the unit I Received— remains in compliance with the reomirements of M.G.L.C.Ig6 22 Date: b BO B 21 mqn *THIS FORM MUST BE FILED WITH THE LOCAL.BOARD OF HEALTH PRIOR TO INITIATING SUBIVIETERING CITY OF SALEM MDPH-CSPSubmreteringFonir,Rev 114-16 BOARD OF HEALTH MASSACHUSETPS 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 Fitness far Human Habitation (State Sanitary Code Chapter II),the following dwelling unit is eligible for the imposition on the tenants of a charge far water and/or sewer service. PROPERTY 1100 HATION -- -- T- Address: 4 First Street 7203 fllriNinudL24 cityrroww Salem MA Zip Code:01970 EQUIPMENT INSTALLATION INFORMATION 105 CMR 410.000 requires the installation of water conservation devices prior to a dwelling unit becoming eligible for the imposition on tenants of a charge for water and/or sewer.The devices must meet the fallowing specifications: Sbowesheads with maximum flow rate not to exceed 24 gallons per minute W gpm) Faucets with maximum flow rate not to exceed 2]no gallons per minute(2.2 gpm) Ultra-low flush water closets(toilets)not to exceed 1 Sf1°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 equipment. Submetering equipment information: Master Meter Flexible Axis Manufhcturer Model# Licensed Plumber Cerfdflcatlon Joseph Bellefeuille 9793 12-16-2019 Print Name of Plumber Licenso# 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 cityhown,if required,is attached ❑Dwelling unit is connected dh=dy to a meter installed by a water company and,in accordance with M.G.L..c.186,1 22(p),does not require the installation of a submeter. Signed under the pains and penalties of perjury, _ r h Cb a Si azure arLicensed P&nber 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 submatering 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 m=sures 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 ender the pains and penalties of perjury, 0- Print Name of Owner Simiatuser of Owner 1 V-L— Date C3 The property has been transfctred to owner above and the unit Received remains in comy lianc a with the mnnuements of M.G.L.c.186 22 Date: by aoiFEB 21 2020 "THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INMATING SUBMETERiNG CITY OF SALEM MDPH-CSP SubmeteringForm,Rev 11-4-16 BOARD OF HEALTH MASSACSUSETTS 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 12),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 y��<7202 24 a crown: Salem bEA pp Code:01970 EQUIPMENT INSTALLATION INFORMATION 105 CMR 410.000 requites the installation of water conservation devices prior to a dwelling unit becoming eligible for the imposition 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 Kjaltons 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 16f10 gallons per flush(1.6 gpf) 7be 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 Wotfcs Association or similar accredited association. A licensed plumber must install the water closets and submetering equipment. Submetedug equipment information: IAaster Meter Flexible Axis Manufacturer Model# Llemed Plumber Ceriiffcatlon Jowph Bellefeuill_e 9793 _ 12-1$72019 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 moan 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 cotmeeted directly to a meter installed by a water company and,in accordance with M.G.L,c.136,§22(p),does not require the installation of submleter. Signed under the pains and penalties of perjury, Sirrsature of Elcensed Progardy Owner Certificatloa I certify that:(1)This dwelling unit is eligible for the imposition on the tenants of a charge for water and/or sewer usage in accordance with the water submetering law(MGL c.186,122);(2)All showerheads,faucets,and water closets in this dwelling unit arse 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 spccified above,or the water meter measuring the use of water is this dwelling unit was installed by a"water company" as defined in M.G.L.c.186,§22; (4)The water meter or submeler 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 information included on this certification is true and accurate to the best of my knowledge. Signed under the pains and penalties ofperjury, 4"' Amtature Print Name of Owner of Owner Date' Tbc property has been ttansfetred to owner above and the unit Received I remains In compliance with the EqatEr=ts of M.O.L.e.196 22 Date: b BOIL 'THIS FORM MUST BE FILED W1TH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBMETERING CITY OF SALEM MDPH-CSP Submetering Form,Rev 11.4-16 BOARD OF HEALTH MASSACHUSETTS DEPARTMElff OF PUBLIC HEALTH SUBMETERING OF WATER AND SEWER CERTIFICATION FORM *In exordance with M.G.L.c.186,§22 and 105 CMR 4I0.000:Minimum Standards of Fitness for Human Habitation (State Sanitary Code Chapter U),the following dwelling unit is eligible for the imposition on the tenants of a charge for water and/or sewer service. PROPERTY INFORMATION rA�licensed s: 4 First Street it 7201 24 own: Salem MA Zi Code;0197t}EQ' ,NM4T INSTALLATION INFORMATIONR 410.000requires the installation of water conservation devices prior toa dwelling unit becoming eligible forthe tion on tenants ofa charge for water and/or sewer.The devices must meet the fallowing specificatioms: heads with maximum flow rate not to exceed 2't bans per minute(2.S gpm) with maximum flow rate not to exceed 2 2n 'gallon per minute(2.2 gpm) w flush water closets(toilets)not to exceed 1 m*gallons per flush(1.6 Slit) metering equipment used to measure the quantity of water used for each dwelling unit and commonareauste standards of accuracy and testing of the American Water Works Association or similar accredited Asoaation. sed plumber must install the water closets and submetering equipment. Submetering equipment information: Master Meter Flexible Axis Manufhcctuer Model# Licensed Plumber Certification .Ioselah l3e11efeuilie 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 I.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. 196,§22(p),does not require the installation of a submeter. Signed under the pains and penalties of perjury, & Si a f Licensed her Property Owner Certl0cation t certify that(1)This dwelling unit is eligible for the imposition an the tenants oFa charge for water and/or sewer usage in accotdance with the wager submctering law(MGL c. 186,§22);(2)All showcrheads,faucets,and water closets in this dwelling unit are water conservation devices that meet the standards specified above;(3)The water submcler measuring the use of water in the dwelling unit was installed by a licensed plumber and is in compliance with the.staudards specified above,or the water meter measuring the use of water in this dwelling unit was installed by a"water company„ as defined in M.G.L,c.186,122; (4)The water meter or submeter measures the water usage exclusive to this unit,(5)1 will pmvide to the tenants of this dwelling unit,prior to occupancy,a written rental agrrxmcmt that dearly 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 a f my knowledge. Signed under the pains and pena[l�ties ofperjury, Vk Print Name of Owner Sienature ofQwner l_, D The property has been transferred no owner above and the unit Date remains in com Malice with the uirements of M.G.L,Q 18 22 Date: RececveBoji EB 21 2020 HO 'THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INMATING S gg�� ggl ���ITF LEnn MDPH-CSP Submetering FaM Rev 11-4-16 BOARD OF HEALTH KASSACRUSETTS DEPARTMIENT OF PUBLIC HEALTH SUBMETERrNG 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 INFORMA77ON -- Address: 4 First Street 7108 24 rsubmmetering wn: Salem MA ZipCode:01970 EQUIPMENT INSTALLATION DWORKATION R 410.000 requires the installation of water conservation devices prior to a dwelling unit becoming eligible for the on on tenants of a charge for water and/or sewer.The devices must meet the following specifications: eads with maximum flow rate not to exceed 2 gallons per minute(2.5 gpm) with maximum flow rate not to exceed 2 gallons per minute(22 gpm) flush water closets(toilets)not to exceed 16"'gallons per flush(1.6 gpf) metering equipment used to measure thee quantity of water used for each dwelling unit and common area must standards of accuracy and testing of the American Water Wodes Association or similar accredited asociation. nsed plumber must install the water closets and submetering equipment. Submetering equipment information: Master Meter FitWtite Axis — ^— Manufacturer Model# Licensed Plumber Certificafa Joseph Bellefeuille 9793 12-16 2019 Print Name of Plumber License# Date I certify that(check all that apply): have installed the submetaing equipment listed above in accordance with accepted plumbing standard. I have installed one or more water closets not exceeding 1.6 gallons per flush. Determined that existing water closets do not exceed 1.6 gallons per flush. i]The plumbing permit issued by the cityttown.if required,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, . Si elute df Licensed bur _ Property Owner Certification I certify that:(1)This dwelling unit is eligible for the imposition on the tenants of a charge for water andlor sewer usage in accordance with the water submetcring law(MGL c.186,§22);(2)All showenccads,faucets,and water closets in this dwelling unit arc 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 complinncc 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 metcr or submeter tncasuuxs the water utsagc exclusive to this unit;(5)I will provide to the tenants of this dwelling unit,prior to occupancy,a written rental agreement nt 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 ofpctjury, es jet fiat 1Vame of awner Sit!nature oownerThe property has been ttansfatred to owner above and the unit remains in com,liance with the uitements of M.G.L c l86 22 Date: cd- "THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SURMETERING CITY OF SALEM MDPH-CSP Submctering Faun,Rev It-4-16 BOARD OF HEALTH MASSACHUSETTS DEPAR'I'1VTENT OF PUBLIC HEALTH SUBMETERING OF WATER AND SEWER CERTIFICATION FORM *In accordance with M.G.L.c.186,§22 and 105 CMR 410.000:Minimum Standards of Frtness for Human Habitation (State Sanitary Code Chapter II),the following dwelling unit is eligible for the imposition an the tenants of a charge for water and/or sewer service. PROPERTY INFOItr ATION Address: 4 First Street 4 ;!n j107. u ,,ter 24 fCoww Salem _ MA _ Zip Code:01970 EQUIPbM4T INSTALLATION INFORMATION 105 CM R 410.000 requires the installation of water conservation devices prior to a dwelling unit becoming eligible for the imposition on tenents of a charge far water and/or sewer.The devices must meet the fallowing specifications: Showerbeads with maximum flow rate not to exceed 2 4 gallons per minute(2.5 Spin) Faucets with maximum flow rate not to exceed 2 gallons per minute(21 Spin) Ultra-tow 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 cash 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. Submatering equipment information: Master Meter Flexible Axis Manufacturer Model 0 Licensed Plumber Certlilcatlon joseptt Bellefeuille _ 9793 12-96-2019 Print Name of Plumber License g Date I certify that(check all that apply): IRAM 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 cttyRown,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 pcdury, S' a ofLi lumber Property Owner Cerdfle2don t certify that:(1)Tbis dwelling unit is eligible for the imposition on the tenants ofa charge for water and/or sewer usage in accordance with the water submctering law(MGL c.186,§22);(2)All showerfiesds,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,§22; (4)'Ile water meter or submeter measures the water usage cxclusive to this unit;(5)t will provide to the tenants of this dwelling unit,prior to occupancy,a written rental agmement 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 Sionature of Owner Date The property has been tranfeu sed to owner above and the unit Date 21 2020 restrains in compliance with the rog`uiretnrnts ar hLG.L.c_186,§22 Date: by H — *THIS FORM MUST BE FILED WITH THE LOCAL HOARD OF HEALTH PRIOR TO INITIATINg"FrTatTM BOARD OF HEALTH tviDPH-CSP 5ubmetering Form,Rev 11.4-15 MASSACHUSETTS DEPARTMENT OF PUBLIC REALTS SUBM.ETERING OF WATER AND SEWER CERTNICATION 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 fallowing dwelling unit is eligible for the imposition on the tenants of charge far water and/or sewer service. PROPERTY INMRXATION Address: 4 First street Unit g7106 24 Citvnbwn: Salem MA Zip Cade:01970 EQUIPM(ENT INSTALLATION INFORKATION 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 far water and/or sewer.The devices must meet the following specificatiions; Sbowerheada with maximum flow rate not to exceed 2"gallons per minute(2.5 gpm) Faucets with maximum flow rate not to exceed 2 pitons per minute(22 gpm) Ultra-tow Bush water closets(toilets)not to exceed 16'10 gallons per flush(1.6 gpf) The submetering equipment used to measure the quantity of water used for each dwelling unit and common area mast meet the standards of accuracy and testing of the American water Works Association or similar accredited association. A licensed plumber must install the water closets and submetering equipment. Submetering equipment information: Master Meter FleAle Axis _ Manufacturer Model# Licenser;Plumber Certification Joseph Belteietalile 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 eityhown.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 pcdury, f ^ 0 Signawii of LiceosqdVimber Property Owner Certification t certify that:(1)This dwelling unit is eligible for the imposition on the tenants of a charge for water and/or sewer usage in accordance with the water submetering low(MGL c.186,§22);(2)All showerhesds,faucets,and water closets in this dwelling unit are water conservation devices that meet the standards specified above;(3)The water 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`wafer company" as defined in M.G.L.c.186,g 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 servim 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 ofpmjury, Print Name of Owner Signature of 0wner L Date D The property has been transfetred to owner above and the unit Receiver EB 21 2020 remains in corn liance with the requirements of M.G.L.c. 186 22 Date: h BOH. GG_ `THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING Se"Ilu SLEM MDPH-05t'Submeteringl:orm,Etev 1 I-4-15 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:Minimum Standards of Fitness for Humus Habitation (State Sanitary Code Chapter II),the following dweUing unit is eligible for the imposition on the tenants of a charge far water andforsewa service. _ PROPERTY INFORMATION - - -FAd&=: 4 First Street 7105 jv nf imim in blelm 24 Ci lI'own Selem MA ZIP Code:01970 EQUIPM1cNT INSTALLATION DWORMATION 105 CMR 410.000 requires the installation of water conservation devices prior to a dwelling unit becoming eligible for the imposition on tenants of a charge for water and/or sewer.The devices must meet the following specifications: Showerhesds with maximum flow rate not to exceed 2 llons per minute(2.5 gpm) Faucets with maximu+ flow rate not to exceed 2 gallons per minute(2.2 gpm) Ultra-low flush water closets(toilets)not to exceed 1*10 gallons per flush(1.6 gpf) The submetering equipment used to measure the quantity of water used for each dwelling unit and common area must meet the 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 infatm don: Master Meter Flexible Axis -- _ Manufacturer Morel# Licensed PI-- er Certification Joseph Betleteuille_ 9793 12-16-2019 Print Nara of Plumjaa License# Date I certify that(check all that apply): i have Installed the submetering equipment listed above in accordance with accepted plumbing standards. I have installed one or more water closets not exceeding 1.6 gallons per flush. Determined that existing water closets do not exceed 1.6 gallons per flush. The plumbing permit issued by the cityltown,if requited,is attached. 0 Dwelling unit is connected directly to a meter installed by a water company and,in accordance with M.G.L.c. 186.§22(p),does not require the installation of a submeter. Signed under the pains and penalties of perjury, _ Si turn Licensed Plumber Property Owner Cerdflcallon 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 showexheads,faucets,and water closets in this dwelling unit are water conservation devices that meat 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 foram;(6)That all information included on this certification is rule and accurate to the best of my knowledge. Signed under the pains and penalties of perjury, Print Name of Owner SiE aWm of Owner Date E D D The property has been transferred to owner above and the unit Received remains in co fiance with the requirements of M.G.L.c. 1116 22 Date: b Ittali:FEB 1 2U2 *THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INMATING SUBMETERING CITY OF SALEM MDPH-CSP SubmeterlugForm,Rev 11-4-16 BOARD OF HEALTH MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH SUBI IXTERING 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 Saailmy 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 �Addrcss: 4 First Street iuiix7104 24 Ci rYbwn: Salem MA Zip Code:01970 EQUIPMENT INSTALI<.ATIONi 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: Showerheads with maximum flow rate not to exceed 2"gallons per minute(2.5 gpm) Faucets with maximum flow rate not to exceed 2 2nO gallons per minute(2.2 gpm) Uttra low flush water closets(toilets)not to exceed i We gallons per flush(1.6 gpf) The submeterin g 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 submeteriog equipment. Submetering equipment information: master deter Flexible Axls Manufacture Model# Llceased Plumber Certification -- .lose it BellefaUlite 9793 _ 12_-16-2019 Print Name of Plumber License# Date Flcert*fy that(cheek 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 cityJtown,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. P Signed under the pains and penalties of perjury, _. IV Si tort of icensed er 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 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 submeter measures the water usage exclusive to this unit;(5)1 will provide to the tenants of this dwelling unit,prior to occupancy,a written rental agreement that clearly provides for the separate charging of water and/or sewer service,and a copy of this certification form;(6)That all information included on this certification is true and accurate to the best of my knowledge. Signed under the pains and penalties of perjury, two , l�-/c Ack Print Name of Owner Siemature of Owner e E Date Ll The property has been transfemd to owner above and the unit Received remains in compliance with the requirements of M.G.L.c. 186 22 Date: b 'OH: F-Rr I z0vo °THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO iNITIATING SUBMETERING CITY OF SALEM MDPH-CSP SubmctcrkgForm,Rev It 4-16 BOARD OF HEALTH MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH SUBMETERING OF WATER AND SEWER CERTIFICATION FORM *In accords=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 LWit 710 24 Ci /Pawn: Salem MA zi Code:01970 EQULPMENT INSTALLATION DMORMATION 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 K gallons per minute(2.5 gpm) Faucets with maximum flow rate not to exceed 2 2NO gallons per minute(2.2 gpm) Ultra-low flush water closets(toilets)not to exceed 1 dta gallons per Bush(l.6 gpf) The submetering equipment used to measure the quantity of water used for each dwelling unit and common area must meet the standards of accuracy and testing of the American Water Works Association or similar accredited association. A licensed plumber must install the water closets and submetrring equipment. Submetering equipment information: Master Meter _ Flexible Axis Manufacum Model# Ucensed Plumber CertiDcation Joseph Beileteuille 9793 1_2-'_l6-2019 Print Name of Plumber License# f 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€lush. 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 submettr. Signed under the pains and penaltics of perjury, L� ¢ v Siiznnture df Licensed ftmbcc 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 submctcring 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 compliamcc with the standards specified above,or the water meter measuring the use of water in this dwelling twit 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 tl►e separate charging of water and/or sewer service,and a copy of this certification fomr(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 pc&ry, Print Name of Owner Simature of Owner H — D hate E3 The property has been transferred to owner above and the unit Receive remains in cam liance with the reauitements of M.G.L.c. 186;_�ate: _by BOH EB 21 2020 *THIS FORM MUST BE FILED VATH THE LOCAL BOARD OF HEALTH k101t TO INMATING SUBMETERING CITY OF SALEM MDPH-CSP SubmatecingForm,Rev 11-446 BOARD OF HEALTH bWSACHUSETPS DEPARTMENT OF PUBLIC HEALTH SUBMETERING OF WATER AND SEWER CERTIFICATION FORM *In accordance with.M.G.L.c.186,§22 and 105 CMR 410.000:Minimum,Standards of Fitness for Human Habitation (State Sanitary Code Chapter U),the fallowing dwelling unit is eligible for the imposition on the tenants ofa charge for water and/or sewer service. - PROPERTY INFORMATION Address: 4 First Street [nit7102 A DLUnits in h1d. 24 ci frown: Salem MA Zi Code;01970 EQNTINSTALLATIONINFORMATION 105 CMR 410.000 requites the installation of water conservation devices prior to a dwelling unit becoming eligible for the imposition on tenants of charge far water and/or sewer.The devices must meet the following specifications: 8howerbesds with maximum flow rate not to exceed 2 x gallons per minute(2.5 gpm) Faucets with maximum now rate not to exceed 2 2nQ gallows per minute(2.2 Spin) I Ultra-low flush water closets(toilets)not to exceed 1 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 similar accredited association. A licensed plumber mush install the water closets and submetering equipment. Submetering equipment':nfarmation: Master Meter Flexible Axis Manufacturer Model# Liex>3sed Plumber Cer*filcation Jose ph Belletectllle 9793 _ _ 12-16-_201_9 Print Name of Plumber Lictmse# Date I really that(check all that apply): I have installed the submctering equipment listed above in accordance with accepted plumbing stLridards. 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,its accordance with M.G.I..c.186,§22(p),does Dot require the installation of a submeter. Signed under the pains and penalties of perjury, �t r c,•(�s Siena o f Licensed Phrmber Property Owner Certification t 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 submetr.ring 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 subnmeter measuring the use of water in the dwelling unit was installed by a liccased 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 wafer 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 true and accurate to the best of my knowledge. Signed under the pains and penalties of pedury, A ..c+ ur ✓ () a, -- F�I-lw Print Name of Owner Sienav=of Owner K`— Date C3 The property has been transferred to owner above and the unit Recei remains in wzn Wee with the air+e merits of M.G.L.a 186 22 Date: b Bt B 21 2020 *THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBMEfERIt L CITY OF SALEM MDPH-CSP 5ubm etering Form,0xv 114-16 BOARD OF HEALTH MAMACRUSETTS DEPARTMENT OF PUBLIC HEALTH SUBMETERICNG 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 H),the following dwelling unit is eligible for the imposition on the tenants of a char for water and/or sewer Barvice. PROPERTY INFORMATION Address: 4 First Street tbWI.7101 24 Ci /Town: Salem MA zirs Code:01970 EQUIPbMNT 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: Sbtrwmheada with maximum flow rate not to exceed 2%jailons per minute(2.5 gpm) Faucets with maximum flow rate not to exceed 2'" gallons per minute(2.2 gpm) Ultra-low flush water closed(toilets)not to exceed 1 6"gallons per flush(1.6 gpl) 'The submetering equipment used to measure the quantity of water used for each dwelling unit and common area must meet the standards of accuracy and testing of the American Water 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 f - Model# Licensed Plumber Certification Joseph Bellefeuille 9793__ 12-16 2019 Print Name:of Plumber � License# Date i certify that(check all that apply): NJ 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 peumit 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.IN,§22(p),does not require the installation of a submeter. Signed under the pains and penalties of perj ury, n __--- -. -•__-_-- IVSixuature o Licensed Plumber Property Owner Certification 1 certify that:(1)This dwelling unit is eligible for the imposition on the tenants of a charge for water and/or sewer usage in accordance with the water 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 treasures 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 certifteation is trite and accurate to the best of my knowledge. Signed under the pains and penalties of pcdury, ts". rt'LL al ,k- 1P., QL Dl Cc Print dame of Owner Sienattnz ofOwner p Date ❑The property has been transferred to owner above and the unit Received remains in cam liance with the reouirements of M.G.L.c.186, 22 Date: by BOH.FEB 21 202 *THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBMETERING CITY OF SALEM MDPH-CSP Submctering Form,Rev 11-4-16 BOARD OF HEALTH MASSACEIUSETTS DEPARTMENT OF PUBLIC HEALTE SUBMETERING OF WATER AND SEWER CERTWICATION FORM *In accordance with M.G.L.c.186,§22 and 105 CMR 410.000:Minimum Standards of Fitaess 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 Tlnita7008 24 Citv/Toww Salem MA Zip Code:01970 EQU BOM INSTALLATION INFORMATION 105 CMR 410.000 requires the installation of water conservation devices prior to a dwelling unit becoming eligible for the imposition on tenants of a charge for water and/or sewer.The devices must meet the fallowing specifications: Showerheads with maximum flow rate not to exceed 2:jallons per minute(2.5 gpm) Faucets with maximum flow rate not to exceed 2 gallons per minute(2.2 gpm) j Ultra-low flush water closets(toilets)not to exceed 1 6"4 gallons per flush(L6 gpf) The submetering equipment used tD 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 infestation: Master Meter Flexible Axis Manufacturer Model# ceased Plumber Certification Joseph Bellefeuilie 9793 12-16-2019 Print Name of Plumber —- License# � Date I certify that(check all that apply): have installed the submetering equipment listed above in accordance with accepted plumbing standards. I have installed one or more water closets not exceeding 1.6 gallons per flush. Deteanined that existing water closets do not exceed 1.6 gallons per flush. The plumbing permit issued by the cityAown,if required,is attached. ❑Dwelling unit is connected directly to a meter installed by a water company and,in accordance with M.G.L.c. 186,§22(p),does not require the installation of a submeter. Signed under the pains and penalties of pcdury, — ' Signature of Licensed Plumber 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 submstering 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 eomplianec 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 pravitie to the tenants of this dwelling unit,prior to occupancy,a written rental agreement that clearly provides for the separate chazEing 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 under the pains and penalties of perjury, Print Name o Owner Signature of Owner Date E3 The property has been transferred to owner above and the unit Receiv remains is EZMpliancc with the rearrirements of M.G.L.c.186 §22 Date: 1by BOIEB 21 2020 *THIS FORM MUST BE FILED W TH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SU &SALEM ING MDPH-CSP Submetering Foam,Rcv 11-4-16 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:Minimum Standards of Fusers for 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 - — —— ---f Address: 4 First Street inif 700g _ Ci min Salem MA zip Code:01970 EQ111£PMENP CMALLATION INFORMATION 105 CMR 410.000 requites the installation of water conservation devices prim to a dwelling unit becoming eligible for the imposition an tenants ofa charge for water and/or sewer.The devices must meet the following specifications: Sbowaheada with maximum flow rate not to exceed V4 gallons per minute(2.5 gpm) Faucets with maximum flow rate not to exceed 2"` gallons per minute(2.2 gpm) Ultra-tow flush waxer closets(toilets)not to exceed 1 ono gallons per flush(1.6 gpf) The submetering equipment used to measure the quantity of water used for each dwelling unit and common area must meet the standards of accuracy and testing ofthe American Water Wades Association or similar accredited association. A licensed plumber must install the water closets and submetering equipment. Submetering equipment information: Master Meter Flexible Axis manufcturer Model# Licensed Plumper Certification Jumph Bellefeuille 9793 _ 1_2-16-2019 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 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,ifrequired,is attached. ❑Dwelling unit is connected dh=dy to a meter installed by a water company and,in accordance with KG.L.c.186,§22(p),does not require the installation of submeter. Signed under the pains and penalties of perjury, S` etuii fLicensed 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 accotdance with the water submetaring law(MGL c.186,§22);(2)All showahc a&,faucets,and water closets in this dwelling unit am water conservation device 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 mcames 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 pmvidas 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 tam and accurate to the best of my knowlcdgm Sighted under the pains and penalties of offperjury, /f Print Name of Owner Signature of Owner tb te 0 The,property has been ttansfemed to owner above and die unit ceiv remains in comMianoe with the mauirernents of M.G.L.c. 186 22 Date BO ggB 11 2020 I TH15 FORM MUST BE FILED V41TH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING ITY SIANGLEM MDPH-CSP Submetering Form,Rev 11.4-16 BOARD OF HEALTH MASSACHUSETTS DEPARTMENT OF PUBLIC KFALTR SUBIVIETERI NG OF WATER AND SEWER CERTIFICATION FORM *ln accordance with M.G.L.c.186,§22 and 105 CMR 410.000:Minimum Standards of Fitness for Ban 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 i Address: 4 First Street 4;?J004- # ��;��En��d�_24 mown: Salem MA zip Code:019T0 i EQUIP 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 ofa charge forwater and/or sewer.The devices must meet the fallowing specifications: Showerheads with maximum flow rate not to exceed 2 K�allons per minute(2 5 gpm) exceed Faucets with maximum flow rate not to 2 gallons per minute(2.2 gpm) Ultra low flush water closets(toilets)not to exceed 16'i0 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 submeteting equipment Submetering equipment information: - Master Meter Flexible Axis Manufacturer Model# Licensed Plumber Certification Joseph Bellefeuille 9793 12-16-2019 Print Name of Plumber License# ~Date I cenify,that(check 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.196,1 22(p),does not require the installation ofa submeter. Signed under the pains and penalties of perjury. u Si matum 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 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 comptiancc 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 metre or submeter measures the water usage exclusive to this unit;(5)I will provide to the tenants of this dwelling unit,prior to occupancy,a written natal agreement that clearly provides for the separate charging orwater and/or sewer service,and a copy of this certification fomn;(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 Sisnatuae of owner LLINE I V FD F te The property has been Umf Bred to owner above and the unit remains in com linece with the mL ILimmenls of M.G.L.e. 186� 22 Date: $OH EB 21 2020 "THIS FORM MIDST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBMETERING CITY OF SALEM MDPH-CSP Submeteing Form,Rev 11-4-16 BOARD OF HEALTH MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH SUBMETERING OF WATER AND SEWER CERTIFICATION FORM 'In accordance with M.G.L.c.196,122 and 105 CMR 410.000:Minimum Standards of Fitness far Humor Habitation (Slate Sanitary Code Chapter 11),the following dwelling unit is eligible far the imposition on the tenants of a charge for water and/or sewer service. PROPERTY INFORMATION Address: 4 First Street i in it a7002 1 24 Ci rrown: Salem MA Zip Code:01970 EQUVMENT INSTALLATION INFORMATION 105 CMA 410.000 requires the installation of water conservation devices prior to a dwelling unit becoming eligible for the imposition on tw nnts of a charge for water and/or sewer.The devices must meet the hollowing specifications: Sbowabeads with maximum flow rate not to exceed 2�llons per minute(2.5 gpm) Faucets with maximum flow rate not to exceed 2 gallons per minute(3.2 gpm) Ultra-low flush water closets(toilets)not to exceed t 6'0 gallons per flush(1.6 gpf) The submetering equipment used to measure the quantity of water used for each dwelling unit and common area must meet the standards of accuracy and testing of the American Water Works Association or similar accredited association. A licensed plumber must install the water closets and submetering equipment. Submetering equipment information: Master Meter Flexible Ards Manufacturer Model# Licensed Plumber Certification Joseph Bellefeullie_ 9793 12-1 fi-2019 Print Name of Plumber License 0 Date i certify that(check all that apply): have installed the submetering equipment listed above in accordance with accepted plumbing standards. I have installed one or more water closets not exceeding 1.6 gallons per flush. Determined that existing water closets do not exceed 1.6 gallons per flush. The plumbing permit issued by the city/town,if required,is attached ❑Dwelling unit is connected directly to a meter installed by a water company cad,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, t � _ Sittra of Lrcensed Plumber i Property Owner Certdfieetiaa I certify that:(1)This dwelling unit is eligible for the imposition on the tenants of a charge for water anudfor sewer usage in accotdaz=with the water submetering law(MGL c.186,§22);(2)All showencoads,faucets,and water closets in this dwelling unit air 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 compliance with the standards specified above,or the water meter measuring the use of water in this dwelling unit was installed by a"water company" as defined in M.G.L c. 196,§22; (4)The water meter or submeter measures the water usage=dusivc 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 ofperjury, Qs 4 Print Name r, OW-ner Signature ofowner- Loll Date The property has been traosfexred to owner above and the unit R"C!1ed FEB 212010 remains in compliance with the requirements of M.G.L.c. 186,_§22 Date: h BOH: *THIS FORM MUST BE FILED WITH THE LOCAL BOARD Of HEALTH PRIOR TO INITIATING SUMETERI Y OF SALEM MDPH-CSP Subnrctering Form,Rev 11.4-16 BOARD OF HEALTH