Loading...
Water submeter certificates - Units in the 8s MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH SUBMETERING OF WATER AND SEWER CERTIFICATION FORM *In accordance with M.G.L.c.186,§22 and 105 Chit 410.000:Minimum Standards of Fitness for Human Habimdon (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 Fast street I F.,,L0308 24 C' mown: Salem MA Zip Code:01970 EQIAPMIM INSTALLATION INFORMATION 105 CMR 410.000 requires the installation of water conservation devices prior to a dwelling unit becoming eligible for the imposition an tenants of a charge for water and/or sewer.The devices must meet the following specifications: 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(22 gpm) Ultra-low flush water closets(toilets)not to exceed 1 d10 gallons per flush(1.6 gpf) The submetering equipment used to measure the quantity of water used for each dwelling unit and common area must meet the standards of accuracy and testing of the 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# Licensed Plumber Certification Joseph Beliefeuilte 9793 _ 12-16-2019 Print Name of Plumber -- License# Date I rectify that(check all that apply): IThe have installed the submetering equipment fisted above in accordance with accepted plumbing standards. have installed one or more water closets not exceeding 1.6 gallons per flush. Determined that existing water closets do not exceed 1.6 gallons per flush.plumbing permit issued by the city/town,ifrequired,is attached ❑Dwelling unit is connected directly to a meter installed by a water company and,in accordance with M.G.L.c.186,§22(p),does not require the installation of a submeter. Signed under the pains and penalties of ped ale i mY, !— --.- -- Sisrtature f Licensed Phmrber Property Owner Certif leadon I certify that:(1)This dwelling unit is eligible for the imposition on the lenants of a charge for water and/or sewer usage in accordance with the water submetering few(MGL c.1$6,§22);(2)All showcrl►cads,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 meta 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 ap 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 ofOwaer Sitaiatute ofOwner 6a - I?-/( Date The property has been traasferred to owner above and the unit Received remains in Compliance with the Mquirements of M.G.L.a 196 §22 Date: b IIOI EB 21 2020 *THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INMA71NG SUBMErERING CITY OF SALEM MDPH•CSP Subnictering Farm,Rev 11-4-16 BOARD OF HEALTH 34[ASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH SUBMETERING OF WATER AND SEWER CERTIFICATION FORM *In acconlance with M.G.L,c.196,§22 and 105 CMR 4I0.000:Minimum Standards of Fitness for Human Habitation (State Sanitary Code Chapter 1I),the 5ollowing dwelling unit is eligible for the imposition on the tenants of a charge for water and/or sewer service. PROPERTY INFORMA77ON Addn=- 4 First Street 07 24 C' down: Salem MA zi Code:01970 EQOIPM 4T INSTALLATION INFORMATION 105 CMR 410.000 requires the iastallatiari of watercenservation devices prior to a dwelling unit becoming eligible for the AV on tenants of a charge for water and/or sewer.The devices must meet the fbllowing specifications: Shaweaheads with maximum,float rate not to exceed 2 s�allons per minute(2.5 gpm) Faucets with maximum flow rate not to exceed 2 gallons per minute(2.2 gpm) tntm-low flush water closets(toilets)not to exceed l d10 gallons per flush(1.6 gpf) The submatering equipment used to measure the quantity of water used for each dwelling unit and common area mast meet the standards of accuracy and testing afthe American Water Works Association or similaraccredited associatio n A licensed plumber must install the water closets and submetering equipment. Submetering equipment information: Master Meter Flexible Axis Manufacturer Modst# Licensed Plumber Certiticadon F�JDMbph 8elleft3ttllie � 9793 12-16-2019 Print Name of Plumber License# - µ Date I certify that(check all that apply): I have installed the submetering equipment listed above in accordance with accepted plumbing standards. 1 have have one or more water closets not exceeding 1.6 gallons per flush. Determined that existing water closets do not exceed 1.6 gallons per flush. The plumbing permit issued by the cityhown,if required,is attached. ❑Dwelling unit is connected directly to a meter installed by a water company and.in accordance with M.G.L.c.196,1 22(p),does not require the installation ofa submeter. Signed under the pains and penalties of perjury, --- Si a of Licensed r Property Owner Certifleatiou 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. 1116,§22);(2)All showe.rheads,faucets,and water closets in this dwelling unit arm water conservation devices that meet the standards specified above;(3)The water submeter measuring the use of water in the dwelling unit was installer)by a licensed plumber and is incompliance with tine 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 exclusive to this unit•,(5)1 will provide to the tenants of Ibis dwelling unit,prior to occupancy,a written rental agreement that clearly provides for the separate charging ofwater and/or sewer service,and a copy of this certification form;(6)That all information included on this certification is true and accurate to the best of my knowledge. Signed under the pains and penalties ofpcdtlm S.L, as / �, (-.net lZ/1` t4 Print Name of Owner Si stun:of Owoec i7 Ile property has bean tr'amsfetred to owner above and the unit Date D Reccived reanams in cow 0taace with the r�ouimneM of M.G.L.c. I. 111 22 Date: b BOH "THIS FORM MUST BE FILED WITH 7HE LOCAL BOARD OF HEALTH PRIOR TO INITIATING S a MDPH-CSP SubMatering Form,Rev 11-4-16 CITY OF SALEM BOARD OF HEALTH MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH SUBMETERING OF WATER AND SEWER CERTIFICATION FORM *In accordance with M.G.L.c.186,§22 and 105 CMR410.000:Mintrau Standardsof F mess for Human Habitation (State Sanitary Code Chapter In,the fallowing dwelling unit is eligible for the imposition an the tenants of a charge for water and/or sewer service. PROPERTY INFORMATION Address: 4 First Street Unit# Ql; cigftiniy, 24 C' (Town: Salem MA Zip Code:01970 EQUIPMENT INSTALLA'li![ON 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:jallons per minute(2.5 gpm) Faucets with maximum flow rate not to exceed 2 gallons per minute(22 gpm) Ultra-tow flush water closets(toilets)not to exceed 1 616 gallons per flush(1-6 gpf) The submetering equipment used to measure the quantity of water used for each dwelling unit and commas area must meet the standards of accuracy and testing of the American Water Works Association or similar accredited association. A licensed plumber must install the water closets and submetering equipment. Submetering equipment information: Master Meter Flexible Aids Manufacturer Model# Cleansed Plumber Cerfication Joseph Sellefeuille 9793 12-16-2019 Print Name of Plumber License# Date I certify that(check all that apply): WIF have installed the submetering equipment listed above in accordance with accepted plumbing standards. I have installed one or more water closets not exceeding 1.6 gallons per flush. Determined that existing water closets do not exceed 1.6 gallons per flush. The plumbing permit issued by the cityAown,ifrequired,is attached ❑Dwelling unit is connected directly to a meter installed by a water company and,in accordance with M.G.L.c.186,§22(p),does not require the installation of a submeten Signed under the gn pains and penalties of perjury, -- _ IV Si¢nsture ofLicensed bar 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 wafer submetering law(MGL c.186,§22);(2)All showerheads,faucets,and water closets in this dwelling unit are water conservation devices that meet the standards specified above;(3)The water submeter measuring the use of water in the dwelling unit was installed by a licensed plumber and is in compliance with the standards specified above,or the water meter measuring the use of water in this dwelling unit was installed by a"water company" as defined in M.G.L.c. 186,§22; (4)The water meter or submeter measures the water usage exclusive to this unit;(5)I wilt provide to the tenants of this dwelling unit,prior to occupancy,a written rental agreement that clearly provides for the separate charging of water and/or sewer service,and a copy of this certification fermi;(6)That all information included on this certification is hero and accurate to the best of my knowledge. Signed under the pains and penalties of perjury, s �s /I � �,,...r ir7 C• �zA tic Print Name of Owner Si azure of Owner M EVEIVED Date C3 The property has been transferred to owner above and the unit Received remains in compliance with the rsnuiremeats of M.G.L.c. 186 22 Date: _by BOH: *THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBMET IW MDPH-CSP SubmeteringForm,Rev 11-4-16 CITY OF SALEM BOARD OF HEALTH MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH SUBMETERING OF WATER AND SEWER CERTIFICATION FORM 'In accordance with M.G.L.c.186,§22 and 105 CMR 410.000.Minimum Standardsof Fitness for Human Habitation (State Sanitary Code Chapter II),the following dwelling unit is eligible for the imposidon on the tenants of a charge for water and/or sewer service. • PROPERTY INFORMATION Address: 4 First Street 05 24 Ifown: Salem MA Zip Code:01970 EQUIP t�NT 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 speciSc�ions; Sbowerheads with maximum flow rate not to exceed 2:pHons per minute(2.S Spin) Faucets with maximum flow rate not to exceed 2 gallons per minute(22 gpm) Ultra-low,flush water closets(toilets)not to exceed 1 don gallons per flush(1.6 gpQ The submetering equipment used to measure the quantity of water used for each dwelling unit and common area must meet the standards of accuracy and testing of the American Water Works Association or similar accredited association. A licensed plumber must install the water closets and submetering equipment Submetering equipment information: Master Meter ReAble Axis Manufacturer Model# Lieeand Plumber Certiflcmdon Joseph SellefeulHe -- 9793 12-16-2019 Print Name of Plumber f` 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 mote water closets not exceeding 1.6 gallons per flush. Determined that existing water closets do not exceed 1.6 gallons per flush. The plumbing permit issued by the cityhown,if required,is attached. ❑Dwelling unit is connected directly to a meter installed by a water company and,in accordance with i M.G.I..c.186,§22(p),does not require the installation of a submeter. Signed under the pains and penalties of perjury, ht 1, ,� SianatureLicertsed er -~- Property Owner Certi icatior 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 accordancc.with the water submetcring law(MGL c. 186,§22);(2)All showetheads,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 complinuce 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 measuaus the water urge exclusive to this unit;( I will provide to the tenants of this dwelling unit,prior to occupancy,a written rental agnxmumt that eleatly provides for the separate charging ofwater and/or sewer service,and a copy of this certification fonn;(6)That all information included on this certification is true and accurate to the best of my knowledge. Signed under the pains and penalties ofpmjwy, •tit,�..1L ey ftiw-�' �� �1-- l b l ' Print Name of Owner S' afore of Owner Date la am 7be property has been ttsfetred to owner above and the unit Received remains in com fiance with the mcuirenents of M.G.L.c. 186 22 Date: b s��$ 212020 *THIS FORM MUST BE FILED WITH THE LOCAL HOARD OF HEALTH PRIOR TO INITIATING SUBMETERING CITY OF SALEM MDPH-CSP Submctering Form,Rev 11.4-16 BOARD OF HEALTH MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH SUBMETERING OF WATER AND SEWER CERTIFICATION FORM *In accordance with M.G.L,e.1116,§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 ofa charge for water and/or sewer service. PROPERTY INFORMATION Address: 4 First Street , . 8304 24 Ci /Town: Salem MA Zi Code:01970 EQUU M>£NT INSTALLATION INFORMATION 105 CMR 410.000 requires the installation of water conservation devices prior to a dwelling unit becoming eligible for the imposition on tenants ofa charge for water and/or sewer.The devices must meet the following specifications: Showerlteads with maximum flow rate not to exceed 2"gallons per minute(2.5 Spin) Faucets with maximum flow rats not to exceed 2 240gallons per minute(22 gpm) Ntra-tow flush water closets(toilets)not to exceed I aro gaitoos 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 similw accredited association. A licensed plumber must install the water closets and submetming equipment. Submetering equipment information: Master Meter Flexible Axis Manufachm Model# Licensed Plumber Certification Jmmnh 0 119feu1119 _ . 9793 12-16-2019 Print Name of Plumber License# Date I certify that(check all that apply): I have installed the submetering equipment listed above in accordance with accepted plumbing standards. I have installed one or more water closets not exceeding 1.6 gallons per flush. Determined that existing water closets do not exceed 1.6 gallons per flush. The plumbing permit issued by the cityAown,if required,is attached. Dwelling unit is connected directly to a meta installed by a water company and,in accordance with M.G.L.c. 186,§22(p),does not tequim the installation ofa submeter. Signed under the pains and penalties of perjury, Simature of Licensed Ph-- 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 subtnctering law(MGL c. 186,§22);(2)All showcdxm s,faucets,and water closets in this dwelling unit an water conservation devices that meet the standards specified above;(3)7be water submeter measuring the use of water in the dwelling unit was installed by a licensed plumber and is in compliance with the standards specified above,or the water meter measuring the use of water in this dwelling unit was installed by a"water company" 1 as defined in M.G.L.c.t 86, 122, (4)The water meter or submeter aeasures 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 pmvidcs for the separate charging of water and/or sewer service,and a copy of this certification form;(6)That all information included on this certification is truc and accurate to the best of my knowledge. Signed under the pains and penalties ofperjury, Print Name of Owner Si atum of Owner Date The Property has beco transferred to owner above and the unit Received remains in compliance with the=uh=ents of M.G.L.m 186 22 Date: b BOM EZU *THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SU EY MDPH-CSPSubmeteringFomt,Rev It 4-16 CITY OF SALEM BOARD OF HEALTH MASSACRUSETTS DEPARTNONT OF PUBLIC HEALTH SUBMETERING OF WATER AND SEWER CERTIFICATION FORM *In accordance with M.G.L.c.186.§22 and 105 CMR 410.000:Minimum Standards of Fitness for Human Habitation (State Sanitary Code Chapter II),the hallowing dwelling unit is eligible for the imposition an the tenants of a charge for water and/or sewer service. PROPERTY INFORMATION FCirown: :4Flr:st treet 8 03 24 Salem MA Zi Code:01970 EQUIPMENT INSTALLATION INFORMATION 105 CMR 410.000 requires the installation of water conservation devices prior to a dwelling unit becoming eligible for the imposition on tenants of a charge for water and/or sewer.The devices must meet the fallowing specifications: Sbowerheads with maximum flow rate not to exceed 2%allons per minute(2.5 Spat) Faucets with maximum flow rate not to exceed 2 p1lons per minute(2.2 Spin) 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 mast meet the standards of accuracy and testing of the American Water Worim Association or simil waccredited association. A licensed plumber must install the water closets and submetering equipment. Submetering equipment infom,ation: Master Meter Flexible Axis Manufacturer Model# Licensed Plumber Certlflcatlon Joseph Beilefeuille 9793 12.16-2019 Print Name of Plumber License# Date I certify that(check all that apply): have installed the submetering equipment listed above in accordance with accepted plumbing standards. I have installed one or more water closets not exceeding 1.6 gallons per flush. Determined that existing water closets do not exceed 1.6 gallons per push. The Plumbing permit issued by the cityltown,ifrequimd,is attached, ❑Dwelling unit is connected directly to a meter installed a water M.G.L.c. 186 22 does not require the installation submeter. and,is accordance with Signed under the pains and penalties of perjury, ' S' censed P Property Owner Certilleatioa tote f Li lumtber 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 slowerlteads,faucets,and watmx closets in this dwelling unit are water conservation devices that meet the standards specified above;(3)The water subtneter measuring the use of water in the dwelling unit was installed by a licensed plumber and is in compliance with the standards specified above,or the water meter measuring the use of water in this dwelling unit was installed by a"water company" as defined in M.G.L.c.186,§22; (4)The water meter or submeter measures the water usage exclusive to this unit;(5)1 Will provide to the tenants of this dwelling unit,prior to occupancy,a written rental agreement that clearly ides fo th on separate charging of water and/or sewer service,and a copy of this certification form;(6) That all information included prov r the this certification is true and accurate to the best of my knowledge. Signed under the pains and penalties of pcdury, x: -wL .rA /.t (- � &uXV- )9�u Print Name of Owner S�ilignatum of Owner LLZJ Date The property has been transferred to owner above and the unit Received mee remains in coat lia with the req uirements of M.G.L.r~ Is6 22 Date: It >3oHTEB 21 202; *THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBMETERING CITY OF SALEM MDPH-CSPSubructeringForm,Rev 11-4-16 BOARD OF HEALTH MASSACUUSETTS 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 Haman Habitation (State Sanitary Code Chapter li),the fallowing dwelling unit is eligible for the imposition on the tenants of a charge tar water and/or sewer service. PROPERTY INFORMATION Addmw. 4 First Street Citvll'own: Salem MA Zi Code:01970 105 C&IIt 410.t100 EQOIpMENT ITISTALLATION INFORMATION requires the installation of water conservation devices prior to a dwelling unit becoming eligible for the imposition oa tenants of a charge far water and/or sewer.The devices must meet the following specifications: Showetbeads with maximum flow rate not to exceed 2"gallons per minute(2.5 gpm) Faucets with maximum flow rate not to exceed 2 vw gallons per minute(2.2 gpm) Ultra-low flush water closets(toilets)not to exceed 1610 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 submeteriug equipmenL Submetering equipment information: Master Meter Flexible Axis -� Manufacturer _ ` ~ Model# Licensed Plumber Cerdacation - ------ Joseph Bellefetlille 9M 12-16 2019 Print Name of Plumber __ T__-� — License# Date I certify that(check all that apply): II have installed the submetergg 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. nc plumbing permit issued by the city/town,if regctired,is attached. C1 Dwelling unit is connected directly to a meter installed by a water company and,in accordanec with M.G.L.c.186,§22(p),does not require the installation of a submeter. Signed under the pains and penalties of perjury, — - Sia2tature of Licensed Plumber Property Owner Certification I certify that:(1)This dwelling unit is eligible for the imposition on the tenants of a charge for water and/or sewer usage in accordance with the water submetcring law(MOIL c. 186,922).(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`%vater 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 ofwaterand/or sewer service,and a copy of this certification form;(6)That all information included on this certification is true and accurate to the best of my knowledge. Signed under the pains and penalties of perjury, l Print Name of owner Signature of owner e D Date The property has been transferred to owner above and the unit Received remains in* liaace with the wairanents of MG.L.c.186 22 Date: b BOH: FEB 21 202 *THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIA?'ING SUBMETERING CITY OF SALEM MDPH-CSP Submetwing Form,Rev It-4-16 BOARD OF HEALTH MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH SUBMETERING OF WATER AND SEWER CERTIFICATION FORM *In accordance with M.G.L.c.186,§22 and 105 CMR 410.000:Minimum Standards of Fitness for Hu=Habitation (State Sanitary Code Chapter D),the folIowing 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 O7 24 Ci !Town: Salem MA Zi Code:01970 EQUIPMENT INSTALLATION INFORMATION 105 CMR 410.000 requires the installation of water conservation devices prior to a dwelling unit becoming eligible for the imposition on tenants of a charge for water and/or sewer.The devices must meet the following specifications: Sbowetheads with maximum flow rate not to exceed 2%gallons per minute(2.5 gpm) Faucets with max exceed maximum flow rate not to 2 gallons per minute(2.2 am) ultra-Iow flush water closets(toilets)not to exceed 1 010 gallons per flush(1-6 gpf) The submatering equipment used to measure the quantity of water used for each dwelling unit and common area must meet the standards of accuracy and testing of the American Water Works Association or similar accredited association. A licensed plumber must into!'the water closets and submetering equipment Submetering equipment information: _ _ Master Meter Flexible Axis -- �___ Manufacturer Model# Licensed Plumber Cerifcation Joseph Bellefeuilte _ 9793 12-116-2019 Ptiat Name of Plumber ~� License# - Date E certify that(check all that apply): 211 have installed the submetering equipment listed above in accordance with accepted plumbing standard& I have installed one or more water closets not exceeding 1.6 gallons per flush. Determined that existing water closets do not exceed 1.6 gallons per flush. 'The plumbing permit issued by the cityhown,if required,is attached. ❑Dwelling unit is connected directly to a meter installed by a water company and,in accordance with M.G.L.c.186,122(p),does not require the installation of a subrneter. Signed under the pains and penalties of perjury, Sisnature 'ceased Plumber Properly Owner Certifleatiori 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 showcnccads,faucets,and water closets in this dwelling unit are water conservation devices that meet the standards specified above;(3)The water submeter measuring the use of water in the dwelling unit was installed by a licensed plumber and is in compliance with the standards specified above,or the water meter measuring the use of water in this dwelling unit was installed by a"water company" as defined in M.G.L.c. 186,§22; (4)The water meter or submeter measures the water usage exclusive to this unit;(5)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 fnim;(6)That all information included on this certification is hue and accurate to the best of my knowledge. Signed under the painsand penalties of perjury, I e�leer Print Name of Owner Sitmature of Owner ►— p Date The property has been transfused to owner above and the unit Received remains in comi3liance with the reouirernants of M.G.L.c. 186,422 Date: b BOt-1= 'THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBMETERING MDPH-CSP SubmeteringFomi,Rein 11-416 CITY OF SALEM BOARD OF HEALTH MASSACRUSETTS DEPARTI UNr OF PUBLIC HEALTH SUBMTERING 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 1%the fallowing dwelEittg unit is eligible far the imposition on the tenants of a charge far water and/or sewer service. PROPERTY INFORMATION - rftucels : 4 First Street 6 24 CIwn: Salem MA Z' Code:01970 EQUIPMENT INISTALLA'ITON INFORMATION R 410.000 requires the installation of water conservation devices prim 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�allons per minute(2.5 gpm) with maximum flow rate not to exceed 2 gallons per minute(2.2 gpm) w flush water closets(toilets)not to exceed I S110 gallons per flush(1.6 gpf) metering equipment used to measure the quantity of water used for each dwelling unit and commlon area must standards of accuracy and testing of the American Water Works Association or similar accredited association. A licensed plumber must install the water closets and suhmeteting equipment. Submetering equipment infmmation: _ _ Master Meter Flexible Axis Manufacturer Model# Licensed Plumber Certfilcatlon Joseph BeiiefeuNte 9793 12-16-2019 Print Name of Plumber 4 — License# Date I certify that(check all that apply): I have installed the subametering equipment listed above in accordance with accepted plumbing standards. I have installed one or more water closets not exceeding 1.6 gallons per flush. Determined that existing water closets do not exceed 1.6 gallons per flush, The plumbing permit issued by the cityhown,if required,is attached. ❑Dwelling unit is connected directly to a meter installed by a water company and,in accordance with M.G.L.c.186,§22(p),does not require the installation of a submeter. Signal under the pains and penalties of perjury, Signature of Licensed Phunber Property Owner Certification 1 certify that:(1)This dwelling unit is eligible for the imposition on the tenants of a charge for water andforsewer 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 measures rho 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 f nut,(6)That all inrormaGan included on this certification is true and accurate to the best of my knowledge. Signed under the pains and penalties of perjury, 4�_k_ —i V—((.Aq Print Name of Owner Signature of Owner F— I k I V., D Date C1 The property has been transferred to owner above and the unit Received remains in con liance with the Mquirements of M.G.L.c. 186 22 Date: b BOH *THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBMETERING MDPH-CSP Submetning Forcer,Rev 114-16 CITY OF SALEM BOARD OF HEALTH MASSAC;USErl S DEPARTMENT OF PUBLIC I +A1r,TA SUBMETERf1'G OF WATER AND SEWER CERTIFICATst' N FORM *In accordance with M.G.L.c>186.§.22 and 105 CMR 410.000:Minimum Standards of Fraim for Hum Habitation (State Sanitary Code Chapter 1I),the fallowing;dwelling unit is eligible far the imposition on the tanants of a charge for wntnr and/or sewer service. f� PROPERTY It FORM TI0N Address: 4 First Cit��lrtnyn: Baleen MA zip Code:019�0 Ht�V7��iT lNSTALL'330N NfORNUTION— 105 C a 410 000 requires the installation of water conservation devices prior to a dwelling unit baconing aligible far the imposition on tenants of a cha9e fcea neater and/or sewer.The devices must meet the followring specifications: Showexhcads with m�x um flow rate not to excttd 2"gallons ptr minute(2.5 gpm) Faucets with maximum flow rate not to exceed 2 rl gallons per minute(2.2 gpm) lilts-low Rush water closets(toilets)not to ea cce 16,10 gallons per Bush(1-6 gprf) Tltc submetering equipment used to measure the quantity of water used for each dwelling unit and common area must meet the standards of accuracy and fcsting of the American Water Works Association or similar accrarlited association. A licensed plumber must install the water closets and submetcring equipment. Submetering equipment information: Master Meter Flexible Axis ManuisctureP Model# Licensed Plumber Carfirleaden JOSeiph Bellefeullte 9793 2-16-2019 Print Name of 1'luasba - Uccnse# Date I car*that(cheep all that apply): I have installed the submetering equipment listed above in accordance with accepted plumbing standards. I have installed one or more water closets not exceeding 1.6 gallons per Bush. Determined that existing water closets do not exceed 1.6 gallons per Bush. The plumbing permit issued by the cityAwwnt,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 submeter, Sued under the pains and penalties of pcdusy, _ p� ----- - - b„-=..------,_ � Stature of Licensed PEurnber Properly Oyster Certification l certify that.(1)11ris dwelling unit is eligible for the imposition on the tenants of a charge 1'cr water and/or sewer usage in accordance with the water subinctcring law(`I GL c. 186,§22);(2)All sbowenc�ads,faucets,and water closets in this dwelling,unit are water conservation devices deal meet the stars specified above;(3)The water submater measuring the use of water in the dwelling unit was installed by a licensed plumber and is in cornpli c with the standards specific above,or the water meter measuring the use of water in elms dwelling unit was installed by a"water company" us defined in XG.L.c. 186,§22; (d)The water rnetcr or subrneter mcasures the water usage exclusive 10 this unit;(5)1 will provide to the:tenants of ibis dwelling unit,prior to occupancy,a written rental age:innent that clearly pmvi far the ...eperate charging P'Xwster and/or se °>cr se, °::c,and ;opy of this cc 'ficad.n€oxen,(ti} tall infa�rmatinn r° ,1�-dad on this certification is true and accu*atc to the best of my Imawledgc. Sued under the pains and penalties ofperjury, 0- tee a a5 v b l€c, Print Name of owner Siztaturc of Owner jg The property has been transferred to owner above and the unit remains in com liance with the G9Rjrcg!cssts of M G.L..c. l86 22 DateB 21 2020 *THIS FORM MUST BE FILED WITH TFE LOCAL BOARD Of HEALTH PRIOR To 11T IA°f1NG SU31v3EfERING CITY OF SALEM M17PH-CSP Submetering Form,Rev 114-16 BOARD OF HEALTH IMASSACHUSE,TTS DEPARTNIMNT OF PUBLIC HEALTH SUBMETERING OF WA I'ER AND SEWER CERTVICATION FORM 'In actor dance with M.O.L.c.186,§22 and 105 CMR 4I0.000:Minimum Standards of Fitaess for Human Habitation (State Sanitary Code Chapter II),the following dwelling unit is eligible for the imposition on the trots of a charge for water and/or sewer service. PROPERTY&FORb'IATION Address: 4 Flrst Street -in bldy-24 C= /Town: Salem MA Zi Code:01970 EQUIPMENT INSTAIrT—kTION DWORMATION 105 CMIt 410.000 requires the installation of water conservation devices prior to a dwelling unit becoming eligible for the imposition an tenants of a charge for water and/or sewer.The devices must meet the fallowing specifications: Sbowetheads with m nimum now rate not to exceed 2gallons per minute(2.3 gpm) Faucets with maximum flow rate not to exceed 2 wo gallons per minute(2.2 gpm) Ultra-low flush water closets(toilets)not to exceed 1 619 gallons per flush(1.6 gpo The submetering equipment used to measure the quantity of water used for each dwelling unit and common area must meet the standards of accuracy and testing of the American Water Works Association or similar accredited association. A licensed plumber trust install the water closets and submetering equipment. Submatering equipment information: _ Master Meter Flexible Axis Maaufacturrr Model# Llcenud Phder Ceafifleation J09eptt Bellefeuille 9793 12-16-2019 Print Name of Plumber License# Date I certify that(check all that apply): IAII 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. Datermined that existing water closets do not exceed I.6 gallons per flush. T'he Plumbing permit issued by the cityhown,if.equised,is attached. Dwelling unit is connected directly to a meter installed by a water company and,in accordance with M.G.L.c. 1116,§22(p),does not require the installation of a submeter. Signed Wider the pains and penalties of perjury, Silmstore of Licensed r Property Owner Certiflcs don l certify that(1)This dwelling unit is eligibly:for thy:imposition on the tenants of a charge fear water n.rWor sewer usage in accordance with the water subrnetetittg law(MOL c 186,§22);(2)All showerhemb,faucets,and water closets in this dwelling unit art water conservation devices that meet the standards specified above;(3)The watersubmater measuring the use of water in the dwelling unit was installed by a licensed plmnber 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 ranter or submeter measures the watex usage exclusive to this unit;(S)1 will provide to the tenants of this dwelling unit,prior to occupancy,a written rental agreement that clearly provides for the separate charging of water and/or scw r riMce,and a cc'-,)y of this certification foam,(6)That all infot.rration included on this certification is tilt~:and accurate to the best of my Imowledge. Signed+,cider the pains/and penalties ofpcdury, �5c. �tuaAi�45 ier "" l2-A. f Print 1Vatrra of Owner —4Sienaftm of Owner D Date 1 he property fans been tcansfetrad to owner above and the unit Received remains in compliance with the r..,uitements of M.G.L.e. 185,422 Date: b BOH *THIS FORM tIr9135I l3£FILED WITH THE L- OCAL HOA:f3 OF HEALTH PRIOR TO€NJTIATINa SUB'tlllE"i EKING MDPH-CSP SubmeteringFonn,Rev 11-4-16 CITY OF SALEM BOARD OF HEALTH MASSACHUSETTS DEPARTMENT OF puBLIC HEALTH SUBMETERLNG OF WATER AND SEWER CERTIFICATION FORM *In accordance with M.G.L,c.186,§22 and 105 CMR 410.000:Minimum Standards of Fitness for Human Habitation (State Sanitary Code Chapter II),the following dwelling unit is eligible for the imposition on the tenants of a charge for water and/or sewer service. PROPERTY INFORMATION Address: 4 First Street 0 bi der 24 ci !Town: Salem MA Zip Code:01970 EQUMMENI'IN5TALLATION 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 andlor sewer.The devices must meet the following specifications: Showerbeads with maximum flow rate not to exceed 2 4gallons per minute(2.5 gpm) Faucets with maximum flow rate not to exceed 2 gallons per minute(2.2 gpm) Ultra-low flush water closets(toilets)not to exceed I pro gallons per flush(1.6 gpQ The submetering equipment used to measure the quantity of water used for each dwelling unit and common area must meet the standards of accuracy and testing of the American Water Works Association or similar accredited association. A licensed plumber must instalt the water closets and submetering equipment. Submetering equipment information; Master Meter Flexible Axis Manufacturer Model# Ueensed Plumber Certifle ation Joseph BellefeUllle 9793 12-16-2019 Print Name of Plumber License# Date I sercify that(check all that apply): I have installed the submetering equipment listed above in accordance with accepted plumbing standards. I have installed one or more water closets not exceeding 1.6 gallons per flush. Determined that existing water closets do not exceed 1.6 gallons per flush. The plumbing permit issued by the cityhown,if required,is attached. Dwelling unit is connected directly to a meter installed by a water company and,in accordance with M.G.L.c.136,§22(p),does not require the installation of a submeter. Signed under the paints and penalties of pcdury, Si ature of licensed %umber Property Owner['�erWIcilan I certify that:(1)This dwelling unit is eligible for the imposition on the tenants oft charge for water and/or sewer usage in accordance with the water submetc6V 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 submetee measuring the use of water in the dweIliag 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&LG.L.,c.186,§22; (4)The water meter or submeter measures the water usage exclusive toads unit;(5)1 will provide to the tenants of this dwelling unit,prier to occupancy,a written rental agreement that clearly provides for the separate charging of water and/or sewer service,and a copy of this certification form;(6)That all information included on this certification is tree and accurate to the best of my knowledge. Signed under the pains and peautties of perjury, Print Name of Owner Si attire of 0wrte r =B=- ,) ne property has been transfemd to owner above and the unit rernains in liance with the uirements of M.G.L.c. 186 22 Date *THIS FORM MUST BE FILED WITH THE LOCAL_BOARD OF HEALTH PRIOR TO INITIATING SUBMET R&I MDPH-CSP Subomtering Form,[rev 11-1-16 CITY OF SALEM BOARD OF HEALTH MASSACHUSETTS DEPARTMENT OF PUBLIC HrALTH SUBIVIETERING OF WATER AND SEWER CERTIFICATION FORM *In accordance with M.G.L.c.186,§22 and lOS CUR 410.000:Minimum Standards of Fitness for Human Habitation (State Sanitary Code Chapter 11),the following dwelling unit is eligible for the imposition on the tenants of a charge for water and/or sewer service. PROPERTY INFORMATION Address: 4 First Street 02 24 a frown: Salem MA Zip Codc:01970 EQUIPMENT INSTALLA I20N INFORMATION 10S CMR 410.000 requires the installation of water conservation devices prior to a dwelling unit becoming eligible for the imposition,on tenants of a charge for water and/or sewer.The devices must meet the following specifications: Sbowerheads with maximum flow rate not to exceed 2 x gallons per minute(2.5 gpm) Faucets with maximum now rate not to exceed 2 zn gallons per minute(2.2 Spin) Ultra-low flush water closets(toitets)not to exceed 16""gallons per flush(1.6 gpf) The submetering equipment used to measure the quantity of water used for each dwelling unit and common arcs must tweet 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 - - - Manufacturer Model# FLicenmd Plumber Certltle ation _ JOSOph Bellefeuille 9793 12-16-2019 Pont Name of Plumber --� L . icense# Date I certify that(check all that apply).- Phave 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. I The Plumbing permit issued by the cityltown,ifre quired,is attached. Dwelling unit is connected directly to a meter installed by a water company and,in accordance with M.G.L.-c. 186,1 22(p),does not require the installation of a submeter. Signed under the pains and penalties of perjury, h � ' .6 Si tWr= f Uicensed Plumber Property Owner Certification I certify that:(1)This dwelling unit is eligible for the imposition on the tenants of a charge for water and/or sewer usage in accordance with the water subtnetcring law(MGL c.166,§22);(2)All showeuhcads,faucets,and water closets in this dwelling unit are water conservation devices that meet the standards specified above;(3)The water submeter measuring the use of water in the dwelling unit was installed by a licensed plumber and is in compliance with the standards specified above,or The water meter measuring the use of water in this dwelling Unit was installed by a`water company„ as defined in M.G.L.c. 186,122; (4)The water meter or submeter measures the wadi usage exclusive to this unit;(5)I will provide to the tenants of this dwelling unit,prior to occupancy,a written rental agreement that clearly provides for the separate charging ofwater and/or sewer service,and a copy of this certification form;(6)That all infomralion included on this certification is true and accurate to the best of my knowledge. Signed under the pains and penalties ofperjtry, Print Name of Owner Signature of Owner D Date 0,The property has been ttans&ntd b owner above and the unit Received remains in compliance with the uirtments of M.G.L.c. 186 22 Date: b BOH: *THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SU E MDPH-CSP Subatclering Form,Rev 11.446 CITY OF SALEM BOARD OF HEALTH MASSACHUSETTS DEPARTMENT OF PUBLIC Hp ALTI3 SUBMETERING OF WATER AND SEWER CERTIFICATION FORM *In accordance with M.G.L.c.186,§22 and 105 CMR 410.000:Minimum Standards of Faness for Human Habitation (State Sanitary Code Chapter In,the following dwelling unit is eligible for the imposition on the tenants of a charge for water and/or sewer service PROPERTY INF`O1I1hiAT7ON [Address: 4 First Street I it 9&01 hidl 24 C' own: Salem MA Zi Code:01970 EQUIPM$NT INSTALLATION INFORMA t ION 105 CMR 410.000 requites the installation of water conservation devices prior to a dwelling unit becoming eligible for the imposition an tenants of a charge for water and/or sewer,lire devices must meet the following specifications: Sbowerbeads 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 gpm) Uhra-low flush water closets(toilets)not to exceed 1 df°gallons per flush(1.6 gpf) The submetering equipment used to measure the quantity of water used for each dwelling unit and common area must meet the standards of accuracy and testing of the American Water Works Association or similar accredited association. A licensed plumber must install the water closets and submetering equipment. Submetering equipment information: Master Meter Flexible Axis Manufacturer 4 Model# Liccnsal Phutahet=CertMcatfon _ Joseph Belleteuille 9793 12-16-2019 Print NameofPiumber License# i certify that(check all that apply): have installed the submetering equipment listed above in accordance with accepted plumbing standards. I have installed one or more water closets not exceeding 1.6 gallons per flush. Determined that existing water closets do not exceed 1.6 gallons per flush. The plumbing permit issued by the cityAown,ifrequired,is attached. ❑Dwelling unit is connected directly to a meter installed by a water company and,in accordance with M.G.L.c.186,§22(p),does not tequim the installation of a submeter. Signed under the pains and penalties of perjury, Risn+ature of 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 xWor sewer usage in accordance with the water subinctering law(MOL 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)7be water submater measuring the use of water in the dwelling unit was.installed by a licensed plumber and is in compliance with the standar ds 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 ropy of this certification tarsi;(6)That all information included an this certification is true and accurate to the best of my knowledge. Signed under the pains and penalties ofperjury, ZSCJ6. [L'..-L aj &C""--"---, (Z a Print Name of Owner Sit'natuae of Owner g t D [)ate The property has been transferred to owner above and the unit Received remains in com fiance with the regakemerits of M.G.L.c. 186,§g22 Date: b BUH: FEB 1 20 U 'THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBEAETERING CITY OF SALEM MDPH-CSP Submetering Form,Rev 114-16 BOARD OF HEALTH MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH SUBMETERING OF WATER AND SEWER CERTIFICATION FORM "In accordance with M.G.L.c.186,§22 and 105 Choir 410.000.Mitrimum 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 WFORMATION� Address: 4 First Street 108 v.W, 24 C' mown: Salem MA Zip Code:01970 EQUEPMMW INSTAEJ ATION 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 fur water and/or sewer.The devices must meet the following specifications: Sbowerlieads with maximum flow rate not to exceed 2 x fallons per minwe(2.5 gpm) Faucets with maximum How rate not to exceed 2" gallons per minute(2.2 gpm) Ultra-tow Hush water closets(toilets)not to exceed 16"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 equtipmeat. Submetering equipment infomnation: Master Meter Flexible Axis f ?�nvfacttuer Model# ~] Licensed Plumber Cerdncation Joseph Bellefe"Ille _9793 12-16-2019 Print Name of Plumber T 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 ptr flush. The plumbing permit issued by the cityftown,if requhV4 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, 5i ature of Licensed Phtmber Property Owner Certltierttlon I certify that:(1)This dwelling unit is eligible for the imposition on the tenants of a charge far water and/or sewer usage in accordance with the water submetering law(MGL c.186,122);(2)Ali showenccads,faucets,and water closets in this dwelling unit am water conservation devices that meet the standards specified above;(3)The water submeter measuring the use of water in the dwelling unit was installed by a licensed plumber and is in compliance with the standards specified above,or the water meter measuring the use of water in this dwelling unit was installed by a"'water company" as defined in M.G.L.c.186,§22; (4)The water meter or submeter measures the water usage exclusive to this unit;(5)I will provide to the tenants of this dwelling unit,prior to occupancy,a written rental agreement that clearly provides for the separate charging ofwater and/or sewer service,and a copy of this certification form;(6)That all information included on this certification is true and accurate to the bat army knowledge:. Signed under the pains and penalties ofpcxjury, sue. mil.— ea S Print Name of Owner. Signature of Owner D �Da, 7'lrc property has bean transferred to owner above and the unit iv remains in con Hance with the nimments of M G.L.c. 186 22 Date- BQ EB 21 2020 *THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SCUiIgIfETERINAGLEM MDPH-CSP SubmderiagForm,rev 11-4-16 BOARD OOFFSHEALTH NIASSACHUSEITS DEPARTNIENI'OF PUBLIC HEALTH SUBMIETERING OF WATER AND SEWER CERTIFICATION FORM *In accordance with M.G.L.c.186,§22 and 105 CMX 410.0W.Mfnimum Standards of Fitness for Human Habitation (State Sanitary Code Chapter II),the following dwelling unit is eligible for the imposition an the tenants of a charge for water and/or sewer service. PROPERTY INFORMATION Address. 4 First Streettimil 1{}7 24 Ci /Town: Salem MA zi Code:01970 'EQUIPNam INSTALLATION WORMATION 105 CMR 410.000 requires the installation of water conservation devices prior to a dwelling unit becoming eligible far the imposition on tettaais of a charge for water and/or sewer.The devices must meet the following specifications; Sbowerheads with mwimurtt flow rate not to exceed 2 gallons per minute(2.5 gpm) Faucets with maximum flow rate not to exceed 2 gallons per minute(2.2 gpm) Ultra-low flush water closets(toilets)not to exceed 1"10 gallons per flush(1.6 gpt) The submetwing 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 submcteriog equipment. Submetetiug equipment information: Master Meter _ Flexible Axis Marlltfacturer Model# lAcensed Plumber Certification Joseph Reilefeuille _ 9793 12-16 2019 Print Name of Plumber License# Date I certify that(cbeck all that apply); I have installed the submelering 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. ?he plumbing permit issued by the city/town,if required,is attached. ❑Dwelling unit is connected directly to a meter installed by a water company and.in accordance with M.G.L.c.186,1 22(p).does not require the installation ofs submeter. Signed under the pants and penalties of perjury, Si �Lc sea Phmi6er Property Owner CerttUicatlon 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 Iaw(MGL c.186,§22);{Z)All showerhmads,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 submeicr measures the water usage exclusive to thi s unit;(S)I wr71 provide to the tenants of this dwelling unit,prior to occupancy,a written rental agreement that clearly provides for t separate charging of water and/or sewer service,and a copy of this certification form;(6)That all information included on this certification is trim and accurate to the best of my knowledge. Signed under the pains and penalties of pet tuy. Print Name of Owner Simature of Owner D Ile property has been transferred to owner above and the unit Rec Dateeived remains in compliance with the regahements of M.G.L.C t8 UA Date: b 13oHEEB 21 2020 *THIS FORM MUST BE FILED WITH THE LOCAL BOARD Of HEALTH PRIOR TO INITIATING SUBMETERING CITY OF SALEM M)PH-CSP Submetering Form,Itev 11-4-16 BOARD OF HEALTH MASSACI USETTS DEPARTIHIENT OF PUBLIC HEALTH SUBMET,EMG OF WATER AND SEWER CERTIFICATION FORK' *In accordance with M.G.L.c.186,§22 and 105 CMR 410.000.Minimum Standards of Fitness for Human Habitation (State Sanitary Code Cbapter II),the fnWwing dwelling unit is eligible far the imposition on the teaiaats of a charge for water and/or sewer service. PROPERTY INFORMATION A ddress: 4 First:Street 106 24 .Seletti MA KiR Code:01970 EQtTVMNT DWALLATION WFORIVIATION 105 CMR 410.000 requires the installation of water conservation devices prior to'a dwelling unit becoming eligible for the imposition on tenants ofa charge for water and/or sewer.The devices must meet the following specifications: Sbowerheads with maximum flow rate not to emceed 2�allons per minute(2.5 gpm) Faucets with maximum flow rate not to exceed 2 gallons per minute(2.2 gpm) Ultra-low flush water closets(toilets)not to exceed 1 6"0 gallons per flush(1.6 gp0 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 Fiextble Axis Manufacturer Made/# Licensed Plumber Cenitication Joseph Belleieuitle 9793 12-16-2019 Print Name of Plumber y 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 galIons per flush. The plumbing permit issued by the cityhown,ifmquimd,is attached. E]Dwelling unit is connected directly to a meter installed by a water company and,in accordance with M.G.L.c. 186,§22(p),does not require the installation of submeter. Signed under the pains and penalties of perjury, Sieinature of Licensed Plumber Property Owner Cardacation I certify that (1)This dwelling unit is eligible for the imposition on the tenants of a charge for water arWor sewer usage in accordance with the water subntctming 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 of water in this dwelling unit was installed by a"water company" Its 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 agmemenrt 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 beat of my knowledge. Signer/under the pains and penalties of perjtuy, t Name of Owner Simeature of Owner 13 Date L The property has born transferred to owner above and the unit Received remains in cop dance with the reouimments of M.G.L.c. 186 22 Date: by BOHE 'THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SO MDPH-CSP Submetering Foram,pcv It-4-16 CITY OF SALEM BOARD OF HEALTH MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH SUBMETERMG OF WATER AND SEWER CERTIFICA17ON FORM "In accordance with M.G.L.c.186,§22 and 105 CMR 410.000:Minimum standards of Fitness far Human Habitation (State Sanitary Code Chapter 14,the hollowing dwelling unit is eligible for the imposition on the tenants of a charge for water and/or sewer servicer;Zowerheadswith PROPERTY INF0RKA7I0N : 4 First Street 105 24 wn Salem MA Zi Code:01970 EQUIP1t+1ENT INSTALLAnON INFORMgT_10N R 410.000 requires the installation of water conservation devices prior to a dwelling unit becoming eligible for the on on tenants ofa charge for water and/or sewer.The devices must meet the fallowing speciScstions: eads with maximum flow rate not to exceed 2K�allons per minute(2.5 rpm)with maximum flow rate not to exceed 2'" gallons per minute(22 gpm) w Rush water closets(toilets)not to exceed l6t10 gallons per push(l.6 gpf) meteting equipment used to measure the quantity ofwater used for each dwelling unit and common area must 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: Idatster Meter Flexible Axis Mamufacnuer Model�! I.lcenud Plumber Certiilmdan dtaaeph Beltefetliile 9793 12-16-2019 Print Name of Plumber License# Date I certify that(check all that apply): I have installed the submetering equipment listed above in accordance with accepted plumbing standards. I have installed one or more water closets not exceeding 1.6 gallons per flush. Determined that existing water closets do not exceed 1.6 gallons per flush The plumbing permit issued by the city/town,if required,is attached. ❑Dwelling unit is connected directly to a meter installed by a water company and,in accordance with M.G.L.c.186,§22(p),does not require the installation of a submeter. Signed under the pains and penalties of pcdury, _ Si ature bf Licensed Plumber Property Owner Cetdileatlon 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 subumuring law(MOL c. 186,§22);(2)All showerbeadL%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,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 ofwater and/or sewer service,and a copy of this certification form;(u)That all information included on this certification is true and accurate to the best of my Imowledge. Signed under the pains and penalties of perjury, Print Name of Owner Sisnature ofOwner — Date The property has been ttansfeaad to owner above and the unit remains in compliance with the rmuirements of M.G.L.c. 186 22 Date: b=B 21 2020 -PHIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SU8METERING CITY OF SALEM MDPH-CSP Submctering Form,Itm 114-16 BOARD OF HEALTH MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH SUBMETERING OF WATER AND SEWER CERTT1lF'[CATION FORM *In accordance with M.G.L.c.186,§22 and 105 CMR 410.000:Minimum Standards of Flb=for Human Habitation (State Sanitary Code Chapter 12),the fallowing dwelling unit is eligible fin the imposition on the tenants of a charge for water and/or sewer service. PROPERTY INFORMATION rftacats s: 4 First Street 8204 24 wn: Salem MA Zip Code:01970 EQUIPMENT INSTALLATION INFORi9fA1RON R 410.000 requires the installation of water conservation devices prior to a dwelling unit becoming eligible for the on an tenants ofa charge farwater 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(21 gpm) w flush water closets(toilets)not to exceed t nogallons per flush(1-6 gpf) metering equipment used to measure the quantity of water used for each dwelling unit and common area must standards of accuracy and testing of the American Water Works Association or similaraccredited association. A licensed plumber must install the water closets and submetering equipmeaL Submetering equipment information: master meter Flexible Axis _, Manufacturer Model# Licensed Plumber Certification Joseph Belletectiile 9793 12-16-2019 Not Name of Plumber License# ©ate I certify that(check all that apply): MI have installed the submetering equipment listed above in accordance with accepted plumbing standards. I have installed one or more water closets not exceeding 1.6 gallons per flush. Determined that existing water closets do not exceed 1.6 gallons per flush. 'Ihe plumbing permit issued by the city/town,ifrequired,is attached. ❑Dwelling unit is connected direetly to a muter inswile d by a water company and,in accordance with M.G.L.c. 1116.122(p),does not require the installation of a submm titer. Signed under the pains and penalties of perjury, f�.. Simmature f Licensed Plumber prop esty Ovrner CerilIItcation 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 wat.:r submetering law(MGL c.186,§22);(2)All showerluads,faucets,and water closets in this dwelling unit are water conservation devices that meet the standards specified above;(3)The water submneter measuring the use of water in the dwelling unit was installed by a licensed plumbc r 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 ibis unit•.(S)I will provido to the tenants of this dwelling unit,prior to occupancy,a written rental agreemcut that clearly provides far the separate chazging of water and/or sower service,and a copy of this certification form;(6)That all information included on this certification is tnoe and accurate to the best of my knowledge. Signed under the pains and penalties of perjury, i6 �(�t Print Name of Owner Simmature ofUwner The property has�trausfetzed to owner above and the uE22 eived remains in emu lianee with the_nuiresmments of M.G.L,c. 186 :Dnter=: bB *THIS FORM MUST BE FILED WITH THEW CA-BOARD OF HEALTH PRIOR TO INITIALING SUBMETERING MDPH-CSPSubmeteringF'orm,Rev 11-4-16 CITY OF SALEM BOARD OF HEALTH MASSACEIUSETTS DEPARTMENT OF PUBLIC KFALTR SUBMETERING OF WATER AND SEWER CERTIFICATION FORM *In accordance with M.G.L.c.186,§22 and 105 Ct►R 410.000:Minimum Standards of Fitness for Bunsen Habitation (State Sanitary Code Chapter II),the fallowing dwelling unit is eligible far the imposition an the tenants of a charge for water and/or sewer service. - PROPERTY INFORMATION �+ Fcity,rrown: ress: 4 First Streethi! 103 24 Salem MA Zi Code:01970 EQUIPKE fTT INSTALLATION INFORKATION 105 CMIR 410.000 requires the installation of water conservation devices prior to a dwelling unit becoming eligible for the imposition on tenants of a charge far water and/or sewer.The devices must meet the following specifications: Showerbeads with maximum flow rate not to exceed 2'c fallons 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 f G16 gallons per flush(1.6 gpo The submetering equipment used to meaS!M the quantity of water used for each dwelling unit and common area must meet the standards of accuracy and testing of the American Water Works Association or similar accredited association. A licensed plumber must install the water closets and submetering equipment. Submetering equipment information: Master Meter Flexible Axis Manufacturer Model# Licensed Plumber Certif ation Joseph Bellefeuille 9793 12-16 2©19 Print Nano of Plumber — License# ^ Date I certify that(check all that apply): I have installed the submetering equipment listed above in accordance with accepted plumbing standards. I have installed one or moan water closets not exceeding 1.6 galloas per flusb. 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 meter installed by a water company and,in accordance with M.G.L.c.186,§22(p),does not require the installation of a submete r. Signed under the pains and penalties of perjury, h� v SinutureifLicensed PKanber Property Owner Certiticatfon I certify that:(1)This dwelling unit is eligible for the imposition on the tenants of a charge for water and/or sewer usage in accordance with the water submetoring law(MGL c. 186,122);(2)All sbowerheads,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 emit 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 M.G.L.c. 186,§22; (4)The water meter or submcter 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 or water and/or sewer service,and a copy of this certification fora;(6)That all information included on this certification is true and accurate to the best of my knowledge. Signed under the pains and penalties ofpajury, Print Name of Owner Signature of Owner Date ©Tbc property has been transferred tQ owner above and the unit Rec°wg 21 2020 remains in eomnlianc a with the: uiretmenis of M.G.L.c. 186 22 Date: b 80 "THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INIT1ATIN66"TTNGEM MDPH-CSPSubmctering Form,Rev It-4-16 BOARD OF HEALTH MASSACHUSETTS(DEPARTMENT OF PUBLIC HEALTH SUBMETERING OF WATER AND SEWER CERTIFICATION FORM *In accordance with M.G.L.c-186,§22 and 105 CMR 410.000•Minimum Standards of Fitness for Human Habitation (State Sanitary Code Chapter II),the fallowing dwelling unit is eligible for the imposition on the laments of a charge for water and/or sewer service. PAOP7i:RTY INFORMATION -- w 4 Rrst Street unk 8102 � ,,. 24 [Addresc i frown: Salem MA Zi Code:01970 EQI WbMgT 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 of a chap for water and/or sewer.The devices must meet the following specifications: Sbawerbeads with maximum flow rate not to exceed 2%gallons per minute(2.5 gpm) Faucets with maximum flow rate not to exceed 2 gallons per minute(2.2 gpm) Ultra-tow flush water closets(toilets)not to exceed t 646 gallons per flush(1.6 gpf) The submetering equipment used to measure the quantity of water used for each dwelling unit and comimoa area must meet the standards of accuracy and testing Of lire A merican Water Works Association or similar accredited association. A licensed plumber must install the water closets and submetering equipment. Submetering equipment information: Master Meter FleAble Axis Manufacture Model# Licensed Plumber Certification .1t�nh a lleieuflle _ 979 _12-16-2019 Print Name of Plumber License# Date i cemify that(check all that apply): have installed the submetetiug 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 cityltown,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 pcduty, h Si tune of Licensed Plumber Property Owner Certification l certify that:(1)This dwelling unit is eligible for the imposition on the tenants of a charge for water and/or sewer usage in accor+daox with the water submetering law(MGL e.186,§22);(2)All showcdx:ads,faucets,and water closets in this dwelling unit an 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 ce,ripa,a water usage y,. ru defined is M.G.L,c.186,§22; (4)The water meter or submNer measures the exclusive to this unit;(5)1 will provide to tho tenants of this dwelling unit,prior to occupancy,a written rental agreement that clearly Provides ear the separate charging of water and/or sewer service,and a copy of this certification fnma;(6)That all information included on this certification is htlo and accurate to the best ofmy knowledge Signed under the pains and penalties ofpajury, .c�-cat d.A cry— f Print Name or Owner Simature ofOwner C D p Date The property has been transferred to owner above and the unit Received rerttains is Hance with the reQuiremrsats of M.G.L c, l86 22 Date:: b H; FEB 2 1 ZO2 SO *THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBileETW9ALEM MDPH-CSP Submeteriog Form,Rcv 11-4-16 BOCC::�AIIRYYDOF HEALTH MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH SUBMETERING OF WATER AND SEWER CERTIFICATION FORM *In accordance with M.G.L.c.186,§22 and 105 CMR 410.000:Minimum Standards of Fitness far Humor Habitation (State Sanitary Code Chapter II),the 6oHowing 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 101 24 /Town: Salem MA ZipCode:0197d EQUIPCYfSW IINSTALL.TION INFOR1t?tAYiol�F 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 foAowing specificadons: Showerheads with maximum flow rate not to exceed 2%gallons per minute(2.5 Spin) Faucets with maximum flow rate not to exceed 2 gallons per minute(2.2 gpm Ultra-low flush water closets(toilets)not to exceed 1 r'�a gallons per flush(1.6 gpf) ) The submetering equipment used to measure the quantity of water used for each dwelling unit and common m area ust 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 Maaufaclhuer Model g Licum d Plumber Certification Joseph Be lefeuille 9793 12A 6-2019 Print Name of Plumber License 6 Date FLc ertify that(check all that apply): MU have installed the submetering equipment listed above in accordance with accepted plumbing standards. I have installed one or more water closets not exceeding 1.6 gallons per flush, Determined that existing water closets do not exceed 1.6 gallons per flush. The plumbing permit issued by the city/town,ifrequired,is attached. ❑Dwelling unit is connected directly to a meta installed by a water company and,in accotdaace with M.G.L.c. 186,122(p),does not require the installation of a submeter. Signed under the pains and penalties of perjury, ' Si f icemed P r Property Owner Certification I certify that:(1)This dwelling unit is eligible for the imposition on the tenants of a charge for water and/or sewer usage in accordance with the water submetering law(MGL c.186,§22);(2)All showerheads,faucets,and water closets in this dwelling unit are water conservation devices that greet the standards specified above;(3)The water submeter neasuring 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 company„ as defined in M.G.L.e. 186,§22; (4)The water motor 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 tic separate charging of water and/or sewer service,and a copy of this certification forhn;(6)Tlhat all information included on this certification is tr>m and accurate to the best of my knowledge. Signed under the pains and penalties of perjury, 2— Print Name of Owner w Si score of Owner D Date The property has been transferred to owner above and the unit Iteceivad remains in Hance with The ufteo=ts of M.G.L c. 18 22 Date: b 80H: FEB 21 20 0 *THIS FORM MUST 131:FlLi D WITH—THE LOCAL BOARD OF HEALTH PRIOR TO INITIA nNe SUBMETERING CITY OF SALEM fNDPH-CS?SubtricteringPorm,Rev 11.4-16 BOARD OF HEALTH MASSACHUSDErTTS DEPARTMENT OF PUBLIC HEALTH SUBMETERING OF WATER AND SEWER CERTIFICATION FORM *in accordance with M.G.L.c.196,§22 and 105 CMR 410.000:Minimum Standards of Fitness for Human Habitation (State Sanitary Code Chapter II),the following dwelling unit is eligible for the imposition on the tenants of a charge for water and/or sewer service. PROPERTY INFORMATION - Address: 4 First Street unit p�pg 24 a Frown: Salem MA ZipCode:I?1971) EQ�M 1fr INSTALLATION INFORMATION 105 CMR 410.000 requires the installation of water conservation devices prior to a dwelling unit becoming eligible for the imposition on tenants ofa charge for water and/or sewer.The devices must meet the following specifications: Showerheads with maximum flow rate not to exceed 2�allons per minute(2.5 gpm) Faucets with maximum flow rate not to exceed 2 gallons per minute(22 gpm) Ultra-tow flush water closets(toilets)not to exceed 1 6'10 gallons per flush CIA 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. Submetcriag equipment infbrmaition: master Met" Flexible Axis -. !Manufacturer Mvciel# T.fcenstd Plumber Certification Jtssepia I3effeieufile 9793 12-113-2019 Print Name of Plumber Cleanse# `emu 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,ifrequited,is attached. Q Dwelling unit is connected directly to a meter Installed by a water company and,in accordance with M.G.L.c.186,§22(p),does act require the installation of a submeter. Signed under the n � P�and penalties of perjury, r•- ,��G �.....� --— -- Si tore of Lictrused Plumber Property Owner Certltieadon 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 vrith the water submetering law(MGL c. 186,§22);(2)All'showerheads,faucets,and wwar 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 cant was installed by a licensed plumber and is in compliance with the standards specified above,or the water meter measuring the use of water in this dwelling unit was installed by a"water company,• as defined in M.G.L.c.186,§22; (4)The water meter or submeter measures the water usage exclusive to this unit;(5)1 will provide to the tenants of this dwelling unit,prior to occupancy,a written rental agreement that clearly provides for the separate charging of water and/or sewer service,and a copy of this certification foray;(6)That all information included on this certification is true and accurate to the best of my knowledge. Signed tmder the pains and penalties of perjury, Las., 4, I'LAC r print Name of Owner Sicnatum ofL3wner Do The property has been transferred to owner above and the unit Received remains in compliance with the uirements of M G.L c.1$6, 22 Date: b BO °tTHIS FORM MUST BE FILED WITH THE LOCAL BOIARD OF HEALTH PRIOR TO INMATING SUBMETERING MDPH-CSF Submetering Form,Rev 11-4-16 CITY OF SALEM BOARD OF HEALTH MASSACHUSETTS DEPARTIVIENT OF PUBLIC HEALTH SUBMETERING OF WATER AND SEWER CERTIFICATION FORM 'In accordance with M.G.L.c.1116.§22 and 105 CMit 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 ofa c ge for water and/or sewer service. PROPERTY INFORMATION rFnu=uwi&h : 4 First Street 24 wn: Salem MA Zi Cade:01970 EQUVMENT INSTALLATION 'ORMATIOIV R 410.000 requites the installation of water conservation devices prior to a dwelling unit becoming eligible for the on on tenants ofa charge far 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(2.2 gpm)flush water closets(toilets)not to exceed 1 artogallons per flush(l.6 gpf)tneterin ui8 eq pment used to measure the quantity of water used for each dwelling unit and common area must standards of accuracy and testing of the American Water Works Association or simt'lar accredited association. A licensed plumber must install the water closets and submetering equipment, Submetering equipment iofbnnadon: Master Meter Flexible Axis V Model# Licerssd Plumber Certification Joseptl l3etlefeUple_ 9793 12-16-2019 Print Name of Plumber License# Date I certify that(check all that apply): have installed the submetering equipment listed above in accordance with accepted plumbing standards. I have Installed one or more water closets not exceeding 1.6 gallons per flush. Determined that existing water closets do not exceed 1.6 gallons per flush. The plumbing permit issued by the cityAowm,if required,is attached j]Dwelling unit is connected directly to a meter installed by a water company and,in accordance with M.G.L.c.186,122(p),does not require the installation ofa submeter. Signed under the pains and penalties of perjury, Si Lure of Licensed Phunber Property Owner Certification t I certlffy that:(1)This dwelling unit is eligible for the ingwsigon on the tenants of a charge for water and/or sewer usage in accordance with the water sametecing law(MGL c. 186,§22);(2)All showenc�ads,faucets,add water closets in this dwelling snit 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 grater compW1 as defined in M.G.L.c.186, §22; (4)The water meter or submeter measures the water usage exclusive to this unit;(5)1 will provide to the tenants of this dwelling unit,prior to occupancy,a written rental agreement that Provides ides for the separate charging ofwater and/or sewer service,and a copy of this certification fomr;(6)That all information included th thus certification is true and accurate to the best of my knowledge. an Signed under the pains and penalties ofpc{jury, Print N=a of Owner Si lure of Owner Eb te The property has been transferred to owner above and the unit ceived am remains in c fiance with the reguirements of M.G.L.c. 186 22 Date: BI EB 21 2020 *THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBMETERING CITY OF SALEM MDPH-CSP Submcteriag Form,Rcv 11-4-I6 BOARD HEALTH MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH SUBMETERING OF WATER AND SEWER CERTIFICATION FORM *In accordance with M.G.L.c.196,§22 and 105 CMR 410.000:Minimum Standards of Fitness for Human Habitation (State Sanitary Code Chapter I1),the following dweftg unit is eligible for the imposition an the tenants of a charge for water and/or sewer service. _ • PROPERT'Y INFORIt+1ATTON Addr=: 4 First Street PnnA 24 City/Town: Ssllem MA Zi Code:019T0 EQUXPMZM INSTALLATION INIR ORKATIOni T 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. Sbowerheads with maximum{law rate not to exceed 2:Vlons per minute(2.5 gpm) Faucets with maximum now rate not to exceed 2 gallons per minute(2Z gpm) ultra-tow flush water claseb(toilets)not to exceed 1&a gallons per flush(1.6 gpt) The submeteriag equipment used to measure the quantity of water used for each dwelling unit and common area must meet the standards of accuracy and tasting of the American Water Works Association or similar accredited association. A licensed plumber must install the water closets and submeteting equipment. Subm atering equipment information: Master meter Flexible Axis Manufacturer Model# Licensed Plumber Certification Joseph Bellsieutlle 9793 12-16-2019 Print Name of Plumber — Lfcpse# 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 required,is attached Q Dwelling unit is connected directly to it meter installed by c water company and,in accordance with M.G.L.c.186,.§22(p),does not require the installation of a submeter. Signed under the pairs and penalties of perjury, !? • -.- --- -•�.__ _ Si tuTeid f Licensed ber r rep"Owner Cerd icatlon I eartify 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 submetcting law(MGL c.196,122),(2)All showerheads,faucets,and water closets in this dwelling unit are water conservation devices that meet the standards specified above;(3)73e water submcter measuring the use of water In the dwelling unit was installed by a licensed plumber and is in compliance with the standards specified above,or the water meter measuring the use of water in this dwelling unit was installed by a"water company', as defined in M.G.L.c.186,§22; (4)The water meter or submeter measures the water usage exclusive to this unit;(5)1 will provide to the tenants of this dwelling unit,prior to occupancy,a written rental agreement that clearly provides for the separate charging of water and/or sewer service,and a copy of this certification form;(6)That all information included on this certification is true and accurate to the best of my knowledge. Signed under the pains and penalties of perjury, �L at; . C �u �a. t"rA- Print Name of Owner K 3imature of Owner Date Q The property has been transferred to owner above and the unit Received remains in con liance with the requirements of M.G.I..c. 196 22 Date: BOfIEB 20 *THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBMETERING CITY OF SALEM MDPH-CSP Submetcdng Form,Rev 11-4-16 HOARD OF HEALTH MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH SUBMXTERING OF WATER AND SEWER CERTWICATIiON FORM *In accordance with M.G.L.c.186,§22 and 105 CMR 410.000:Minnaum 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 002' rro� Salem MA Zip Code:01970 EQU PUMM INSTALLATION INFORK&TION OS CMR 410.000 requires the installation of water conservation devices prior to a dwelling unit becoming etigt'ble for the imposition on tenants of a cbatge for water and/or sewer.The devices must meet the fallowing specifications: Showecheads with maximum flow rate not to exceed 2%gallons per minute(2.5 gpm) Faucets with maximum flow rate not to exceed 2"' gallons per minute(22 glum) Ultra-tow flush watercktse4t(toilets)not to exceed 1 a'uo gallons per flush(1.6 gpl) The submetering equipment used to measure the quantity of water used for each dwelling unit and common area must meet the standards of accuracy and testing of the American Water Works Association or similar accredited association A licensed plumber must install the water closets and submetering equipment. Submetering equipment information: Master Meter ReAble Axis i Manufacturer Mode! Licensed Plumber Cectlf#eatiott .Jrmafth Belleteuille 9793 _ 12-16-2019 Print Name of Plumber License#/ Date I certify that(check all that apply): J have installed the submetering equipment listed above in accordance with accepted plumbing standards. I have installed one or mote water closets not exceeding 1.6 gallons per flush. Determined that existing water closets do not exceed 1.6 gallons per flush. j The plying permit issued by the city/town,if required,is attached. ❑Dwelling unit is connected directly to a motor installed by a water company and,in accordance with M.G.L.c. 186,§22(p),does not require the installation ofa submeter. Signed tinder the pains and penalties of perjtuy, Si store of Licensed Phunber Property Owner Certiiiication I certify that:(1)This dwelling unit is eligible for the imposition on the tenants ofa charge fix water and/or sewer usage in accordance with the water submetcring law(MGL c. 186,122);(2)All showerheads,faucets,and vMcr closets in this dwelling unit art water conservation devices that meet the standards specified above;(3)The water submeter measuring the use of water in the dwelling unit was installed by a licensed plumber and is in compliance with the standards specified above,or the water meter measuring the use of water in this dwelling unit was installed by a"water company,• as defined in M.G.L.c.186,§22; (4)The water meter orsubmeter 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 ofwater and/or sewer service,and a copy of this certification faun;(6)That all information included on this certification is true and accurate to the best of my knowledge. Signed under the pains and penalties ofperjury, Print Name of Owner Simature ofOwner D Date ©The property has been transferred to owner above and the unit Received remains in coin liance with the rnuuairements of M.G.L.a l86 22 Date: b s©�EB 21 2020 'THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIAT'lNS SUBME ERING CITY OF SALEM MDPH-CSP Submetering Form,Rev 11-4-16 BOARD OF HEALTH