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Water submeter certificates - Units in the 9s MASSACHUSEITS DEPARTMENT OF PUBLIC HEALTH SUBMXTERING 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 Il),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 9 08 24 Ci Town: Salem 1VIA Zip Code:01970 EQUIPMENT INSTALLA.TiON INFORmATtON 105 CMR 410.000 requires the installation of water conservation devices prim'to a dwelling unit becoming eligible for the imposition on tenants of a charge for water andlor sewer.The devices must meet the following specifications: Showetheads 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) Ultra-low flush water closets(toilets)not to exceed 16010 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 tasting of the American Water Works Association or simiter accredited association. A licensed plumber must install the water closets and submetering equipment. Submetering equipment infomaation: Master Meter Flexible Axis Model# manufacturer Licensed Plumber Certification _ Joseph Bellefeuille 9793 � 12-18 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. 1 have installed one or more water closets not exceeding 1.6 gallons per flush. Determined that existing water closets do not exceed 1.6 gallons per flush. The plumbing permit issued by the cityRown,if required,is attached. ❑Dwelling unit is connected directly to a nester 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¢na `oF icensed 1'lumrber Property Owner Certification I certify that:(1)This dwelling unit is eligible for the imposition an the tenants of a charge rar water mWor sewer usage in accordance with the water submetering law(MGL c.186,122);(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 orwater in this dwelling unit was installed by a"water company" as defined in M.G.L.c.186,§22; (4)The water meter or submeter measures the water usage exclusive to this unit;(S)I will provide to the tenants of this dwelling unit,prior to occupancy,a written rental agreement that clearly provides for the separate charging of water and/or sewer service,and a copy of this certification form;(6)That all information included on this certification is true and accurate to the best of my knowledge. Signed under the pains and penalties of perjury, as +Car d~ i2- t fa AA Print Name of Owner Signature of Owner ° E D property has been transferred to owner above and the unit Recemains in Hance with the uirarrcrrts of M.G.L.e. 186 22 Date: -Sih BOH: F 0 *THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INrIATING SUSMETERING CITY OF SALEM MDPH-CSP Submetering Form Rev 11.4-16 BOARD OF HEALTH MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH SUBMETERING OF WATER AND SEWER CERTIFICATION FORM *In accordance with M.G.L.c.186,§22 and 105 CMR 410.000:Minimum Standards of Fitness for Human Habitation (State Sanitary Code Chapter U),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 Street 9307 • i ! _24 C' II'owa: Salem MA Zi Code:01970 EQI7IPMENT 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 4"-gallons per minute(2.S gpm) Faucets with maximum flow rate not to exceed 1 gallons per minute(22 gpm) Ukra-low flush water closets(toilets)not to exceed 16110 gallons per flush(L6 gpf) The submetering equipment used to measure the quantity of water used for each dwelling unit and common area most meet the standards of accuracy and testing of the American Water Wodcs Association or similat accredited association. A licensed plumber must install the water closets and submetering equipment. Submetering equipment information: Master Meter � Flexible Axis Manufacturer Model# Licensed Plumber Certification _ Joseph Bellefeuille 9793 12-1 fi-2019 Print Name of Plumber License# Date I certify that(check all that apply): I have installed the submatering equipment listed above in accordance with accepted plumbing standards. I have installed one or more water closets not exceeding 1.6 gallons per flush. Determined that existing water closets do not exceed 1.6 gallons per flush. The plumbing permit issued by the cityltown,if required,is attached ❑Dwelling unit is connected directly to a meter installed by a water company and.in accordance with M.G.L.c.186,§22(p),does not require the installation of a submeter. Signed under the pains and penalties of perjury, L (' Smoatute orLicensedlIkifiber 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(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&"water company" at 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 I mowledge. Signed under the pains and penalties of perjury, t't tL 41 O Aj,,Ltt, tQt Print Name of owner Signature of Owner Date HECEIVED Date O The property has been tramsfeaed to owner above and the unit Received remains in con liaace with the mamirements of M.G.L.c. 186 §22 Date: 'mv BOH: *THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO TNlT1ATING SUS _� MDPH-CSP Subructering Form,Rev 114.16 CITY OF SALEM BOARD OF HEALTH MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH SUBMETERING OF WATER AND SEWER CERTIFICATION FORK *In accordance with M.G.L.c.196.122 and 105 CMR 410.000:Minimum Standards of Fitness for Human Habitation (State Sanitary Code Chapter 11),the following dwelling unit is eligible for the imposition on the tenants of a charge for water and/or sewer novice. PROPERTY INFORMATION Address: 4 First Street F, • g ina 24 Cityfrow. Salem MA Z' Code:01970 EQ1ilVMW4T 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(L5 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 dt0 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 similar accredited association. A licensed plumber must install the water closets and submetering equipment. Flexible Axist Meer Subaxtering equipment information: Master w Model# Manufacttuer ___ ---- Licensed Plumber Certification Joseph Beilefeuiile � 9793 12-16-2019 Print Name of Plumber License# Date I certify that(check all that apply): I have installed the submetering equipment listed above in accordance with accepted plumbing standards. I have installed one or more water closets not exceeding 1.6 gallons per flush. Determined that existing water closets do not exceed 1.6 gallons per flush. The plumbing permit issued by the cityhown,ifrequired,is attached. ❑Dwelling unit is connected dirce ly 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 atute of is Plumber I J Property Owner Certification I certify that:(1)This dwelling unit is eligible for the imposition on We tenants of a charge for water and/or sewer usage in accordance with the water submetering law(MGL c. 186,§22);(2)All showerhcads,faucets,and water closets in this dwelling unit are water conservation devices that meet the standards specified above;(3)The water submew 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 writica rental agreement that clearly provides far the separate charging of water and/or sewer service,and a copy of this certification fbnn;(6)That all information included on this certification is Gate and accurate to the best of my knowledge. p �e Signed under the pains and penalties of perjury, R E V E I V E Print Name of Owner Silmature of owner ie Date The property has been transferred to owner above and the unit Roc fYf� OF SALEM remains is compliance with the uitnments of M.G.L c.186 22 Date: h *THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBMErERiNd MDPH-CSP Submctaft Form,Rev 11-4-16 MASSACHUSETTS DEPARThUNT OF PUBLIC HEALTH SUBMETERING OF WATER AND SEWER CERTIFICATION FORME' *In accordance with M.G.L.c.186,122 and 105 CMR 410.000:Minimum Standards of Fitness for Human.Habitation (State Sanitary Code Chapter In,the following dwelling unit is eligible for the imposition on the tenants of a charge for water and/or sewer service. .----- PROPERTY INFORMATION Address: 4 First Street 9305 #nf in;ts;n,,id 24 C; Rowe: Salem MA zl Code:01970 EQUIPMffiNT INSTALLATION INFORMATION 105 CMR 410.000 requires the installation of water conservation devices prim to a dwelling unit becoming eligible for the imposition on tenants of a cbarge forwater and/or sewer.The devices must meet the following specifications: Sbowerbeads with maximum flow rate not to exceed 2"gallons per minute(15 spin) Faucets with maximum flow rate not to exceed 2 2no gallons per minute(2.2 spin) j Ultra-low flush water closets(toilets)not to exceed 1010 gallons per Gush(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. Flexible Axist Meer Subraeteriag equipment information: Master T" Model# Manufacturer Licensed Plumber Certification Joseph Bellefeuilie 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 cityAowa,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. Ltquer7 Signed under the pains and penalties of perjury, Signature of Licensed PiuMber 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 law(MGL c.186,§22);(2)All showerbeads,faucets,and water closets in this dwelling omit are water conservation devices that meet the standards specified above;(3)The water submeter measuring the use of water in the dwelling unit was installed by a licensed plumber and is in compliance with the standards specified above,or the water meter measuring the use of water in this dwelling unit was installed by a"water company" as defined in M.G.L.c.186,122; (4)The water meter or submeter measures the water usage exclusive to this unit:(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, 12.11� e9 Print Name of Owner Signature of Owner Date — Date �EIVE The property has been transferred to owner above and the unit Rec v remains in comb/lance with the reonirements of M.G.L.c. 186 22 Date: by BOH: *THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING S'PREJE�I(A20 MDPH-CSP Submetaing Form,Rev 11-4-16 BOARD HEALTH MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH SUBMETERING OF WATER AND SEWER CERTIFICATION FORM *In accordance with M.G.L.e.196,122 and 105 CMR 410.000:Minimum Standards of Fitness for Human Habitation (State Sanitary Code Chapter II),the following dwelling unit is eligible for the imposition an the tenants of a chuge for water and/or sewer service. PROPERTY INFORMATION Address: 4 First Street unit 0304. 24 C' drown• 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 textants of a charge far water and/or sewer.The devices trust meet the following specifications: Sbowerheads with maximum flow rate not to exceed 24 gallons per minute(2.5 gpmn) Faucets with maximum flow rate not to exceed 2 zqo gallons per minute(2.2 gpm) ultra low flush water closets(toilets)not to exceed 161111 gallons per flush(1.6 gpQ 1 The submetering equipment used to measure the quautity of water used for each dwelling unit and commas area must 1 tweet the standards of accuracy and testing of the American Water Worts Association or similar accredited association. A licensed plumber must install the water closets and submetering equipmeaL ` Flexible Axist Me ter eer I Subtrxtering equipment infaraiation: MasterModel# Manufacturer Lie ewed Plumber Certification Joseph Bellefeuille 9793 12-16-2019 Print Name of Plumber License# Date 1 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. Detlosets do not eed 1.6 gallons per The plumbing g t existing water permit Issued bycthe eity/town,fcrequired attached.flush. The plumbing p ❑Dwelling unit is connected directly to a outer installed by a water company and,in accordance with M.G.L.c.186,122(p).does not require the installation of a submeter. n , Signed under the pains and penalties of perjury, —Siommum 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 I in accordance with the water submetering law(MGL c.186,§22);(2)All showerheads,faucets,and water closets in this 1 dwelling unit are water conservation devices that meet the standards specified above;(3)The water submeter measuring the use of water in the dwelling unit was installed by a licensed plumber and is in compliance with the standards specified above,or the water meter measuring the use of water in this dwelling unit was installed by a"water company" as defined in M.G.L.c. 186,122; (4)The water meter or submeter measures the water usage exclusive to this units(5)I win provide to the tenants of this dwelling unit,prior to occupancy,a written rental agteememt that cltacly pm do for the separate charging orwater and/or sewer service,and a copy of this certification font;(6)That all information included on this certification is itue and accurate to the best of my knowledge:. Signed under the pains and penalties of perjury, R la 6 E I V E Z Xi Print Name of Owner Si ature of Owner to Date O The property bas been transferred to owner above and the unit Rece�v OF SALEM remains in compliance with the uirements of M.G.L.c. 186 22 Date: b *THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO iNIT1A MDPH-CSP Subrnctertng Form,Rev 11.4-16 MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH SUBMETERING OF WATER AND SEWER CERTIFICATION FORM *In accordance with M.G.L.c.l 86,§22 and 105 CMR 410.000:Minimum Standards of Fitoess for Human Habitation (State Sanitary code Chapter El time following dwelling unit is eligible for the imposition an the tenants of a charge far water and/or sewer service. _ PROPERTY INFORMATION Address: 4 First Street jna m9303 24 Ci IToww Salem MA Zip Code:01970 EQUIPMENT INSTALLATION INFORMATION 105 CMR 410.000 requires the installation of water conservation devices prior to a dwelling unit becoming eligible for the imposition on tenants of a charge for water and/or sewer.The devices must meet the following speei8cations: Showerhe ads with maximum Hoar rate not to exceed 2'r gallons per minute(2.5 gpm) Faucets with maximum now rate not to exceed 2 m gallons per minute(2.2 gpm) Ultra-tow flush water closets(toilets)not to exceed 1 mQ 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 Watar Works Association or similar accredited association. A licensed plumber must install the water closets and submetering equipment. SubmersingMaster Meter Flexible Axis equipment info:amation: ---J Model# Manufacture Y Licensed Plumber Certification Joseph Sellefeullle 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 cityhown,ifrequired,is attached. ❑Dwelling unit is connected directly to a meter installed by a water company and,in accordance with M.G.L.c.186,§22(p),does at require the installation of a submeten Signed under the pains and penalties of perjury, AeL Sieaeatetr+'e of L" s u Property Owner CertiIIcatlon 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 mot&=with the water submetering law(MGL c.186,§22);(2)All showmimads,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 phunber and is in compliance with the standards specified above,or the water meter measuring the use of water in this dwelling unit was installed by a`Nate company" as defined is M.G.L.c.186,§22; (4)The water meter or submeter mexsures the water usage exclusive to this unit;(5)1 will provide to the tenants of this dwelling unit,prior to occupancy,a written rental agreement that clearly provides for the separate charging orwater and/or sewer service,and a copy of this certification form;(6)That all information included an this certification is true and accurate to the best a f my knowledge. Signed under the gams and penalties of perjury. Print Name of Owner -4Mmatume of Uwner Date C3 IMe property has been transferred to owner above and the unit Reee1°e'FEB 21 202 remains in cum liance with the uirements of M.G.L.c. 186 22 Date: h BDH: 'THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SWW'5LEM BOARD OF HEALTH MDPH-CSp Submawring Form,Rev 11-4-16 B ASSACHUSETTS 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 (Stale Sanitary Code chapter JI),the following dwelling unit is eligible for the imposition on the tenants of a charge for water and/or sewer 8:t vice. PROPERTY INFORMATION Address: 4 First Street Unit 11.9302 24 citymown: Salem MA zi code:01970 EQURNMNT INSTALLATION INFORMATION 105 CMR 410.000 requires tine installation of water conservation devices prim to a dwelling unit becoming eligible for the imposition on tenants of a charge for water and/or sewer.The devices must meet the fallowing specifications: Showerheads with maximum flow rate not to exceed 2"',_gallons per minute(2.5 gpm) Faucets with maximum flow rate not to exceed Z gallons per minute 0-2 gpm) Ultra-low flush water closets(toilets)not to exceed 16010 gallons per flush(1.6 gpO The submetering equipment used to measure the quantity of water used for each dwelling unit and common area must meet the standards of accuracy and testing of the American Water Works Association or similar accredited association. A licensed plumber must install the water closets and submetering equipment. Flexible Axist Meer Submeteriag equipment information: Master Model# Manufacturer ;dceased Plumber Certification Joseph Bellefeuille 9793 12-16-2019 Print Name of plumber License# Date I certify that(check all that apply): t 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.a 186,§22(p),does not require the installation of a submeter. Signed under the pains and penalties of perjury, V—_ Sipatific of Licensed Agiber Property Owner Certmedon t certify that:(1)This dwelling unit is eligible for the imposition on the tenants of a charge for water and/or sewer usage in accordance with the water submetering law(MGL c.186,§22);(2)All showcnccads,faucets,and water closets in this dwelling unit ate water conservation devices that meet the standards specified above,(3)The water submeter measuring theuse of water in the dwelling unit was installed by a licensed plumber and is in compliance with the standards spaified above,or the water meter measuring the use orwater 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 tmants-of Ibis 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,fit►+ rrau - 6 1LKEGE�V Print Name a Owner Siena re of Owner Date Date FEB 21 20 0 The property has been transferred to owner above and the unit Received remains in c❑m liance with the rcouirements of M.G.L.c.185 22 Date: SOH: ALCM 'THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRlORT011i111lAlifVG SM HEALTH MDPH-CSP Subinetering Form,Rev 114-16 MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH SUBMETERING OF WATER AND SEWER CERTIFICATION FORM *In accordance with M.G.L.c.1116,§22 and 105 CMR 410.000:Minimum Standards of 1;<<tnew for human Habitation (State Sanitary Code Chapter I1),the following dwelling unit is eligible for the imposition on the tenants of a chur for water and/or sewer service. PROPERTY INFORMATION Address: 4 First Street urat#9301 24 Ci n.own. Salem MA Zi Code:01970 EQ'[lIPR NT INSTALLATION INFORMATION 105 CIV1R 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 trust meet the fallowing specifications: Sbowerheads with maximum flow rate not to exceed 2�llons per minute(2.5 Spin) Faucets with maximum flow rate not to exceed 2 gallons per minute t2.2 gpm) Ultra-tow flush water closets(toilets)not to exceed 16no 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 simitarac credited association. A licensed plumber must install the water closets and submetering egluipmeat. Submete ring equipment infomnation: Master Meter Flexible Axis Manufacturer Model# Licensed Plumber Certltteatlon Joseph Beilefeullle 9793 1246 2019 Print Name of Plumba 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 Rush. The plumbing permit issued by the cityltown,if required,is attached. ❑Dwelling unit is connected directly to a metes installed by a water company and,in accordance with M.G.L.c.1g6,§22(p),does not require the installation of a submeter. Signed under the pains and penalties of perjury, +` S' lure of Licensed M=ber Property Owner Certification t certify that:(1)This dwelling unit is eligible ror the imposition on the tenants of a charge for water and/or sewer usage in accordance with the water submetering law(MOL e.186.122);(2)All sbowenccads,faucets,and water closets in this dwelling unit are water conservation devices that meet the standards specified above;(3)The water submeter measuring the use of water in the dwelling unit was installed by a licensed plumber and is in compliance with the standards specified above,or the water meter measuring the use of water in this dwelling unit was installed by a"water company" as defined in M.G.L.c.186,§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 ror the separate charging of water and/or sewer service,and a copy of this certification fora;(6)Tbat ail 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 or owner SienatureofUwner DAft V ED FrB, 17 The property has been transfemd to owner above and the unit ived remains in compliance with the: nir+emenls of M.G.L.e:.186 22 Date: H: 2020 *THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SU01V1ET I CITY OF SALEM MDPH-CSP SubmeteringForm,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.1196,122 and 105 CMR 410.000:Minimum Standards of Fitness for Human Habitation (State Sanitary Code Chapter 11),the 6ollawing dwelling unit is eligible for the imposition on the tenants of a charge far water and/or sewer service. —--- PROPERTY INFORMATION Address: 4 First Street ijit#920$ 24 CiilTerwa• 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 forwawr and/or sewer.The devices must meet the following specifications: Showerheads with maximum flow rate not to exceed 2"gallons per minute(L5 Spin) Faucets with maximum How rate not to exceed Z gallons per minute(2.2 Spin) Ultra-tow flush water closets(toilets)not to exceed I"gallons per Bush 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. Submetering equipment information: _ Master Meter w� Flexible Axis Manufacturer M10# Licensed Plumber Certification _ Joseph Bellef eulile 9793 12-1$-2019 Print Name of Plumber License# Date Ice ttify 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 flash. Detennined that existing water closets do not exceed 1.6 gallons per flush. ' The plumbing permit issued by the cityRown,if required,is attached. ❑Dwelling unit is connected directly to a meter installed by a water company and,in accordance with M.G.L..c.186,1 22(p),does not require the installation of a submeter. Signed under the pains and penalties of perjury, signature dr ticensed P14hber 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(MGL c.186,§22);(2)All showenccads,faucets,and waterclosets in this dwelling unit are water conservation devices that meet the standards specified above;(3)7be water submeter measuring the use of water in the dwelling emit was installed by a licensed plumber and is in complimm with the standards specified above,or the water meter measuring the use of water in this dwelling unit was installed by a"water company" as defined in M.G.L.c.186,122; (4)The water meter or submeter measures the water usage exclusive to this unit;(S)I will provide to the tenants of this dwelling unit 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 farm;(6)That all information included on this certification is true and accurate to the best of my knowledge. Signed under the pains and penalties of perjury, a, Print Name of Owner Simtature of Owner Date IMIMFUEIVED la The property has been hansfexred to owner above and the unit Received restrains in compliance with the uire:rnerrts of M.G.L.c. 186 22 Date: by BOR e1THiS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATIN MDPH-CSP Submetering Form,Rev 11.4-16 BOARDTF EA M H MASSACHUSETPS DEPARTMENT OF PUBLIC HEALTH SUBMETERI NG OF WATER AND SEWER CERTIFICATION FORM *In accordance with M.G.L.c.186,§22 and 105 CNtR 410.000:Minimum Standards of fritness 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 Street 9207 garuaiftinhifig.24 city/Town: Salem MA zi Code:01970 EQUI PKLW INSTALLATION INFORMATION 105 CMR 410.000 requites the installation of water conservation devices prior to a dwelling unit becoming eligible for the imposition on tenants of a charge for water and/or sews The devices must meet the following specifications: Showerheads with maximum flow rate not to exceed 2 a gallons per minute(2.5 gpm) Faucets with maximum flow rate not to exceed 2>n gallons per minute(2.2 gpm) Ultra tow flush water closets(toilets)not to exceed i earo 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 simileraccredhed association. A licensed plumber must install the water closets and submetering equipment. Submetering equipment information: Master Meter Flexible Axis Manufacturer Model# Licensed plumber CertMe s a Joseph Bellefetlille 9793 12-16-2019 Print Name of Plumber License# Date I certify that(cha k all that apply): have installed the submetering equipment fisted above in accordance with accepted plumbing standards. 1 have installed one or more water closets not exceeding 1.6 gallons per flush. Determined that existing water closets do not exceed 1.6 gallons per flush. The plumbing permit issued by the cityltown,if required,is attached. ❑Dwelling unit is connected directly to a meter installed by a water company and.in accordance with M.G.I..c.186,122(p).does not require the installation of a submeter. Signed under the pains and penalties of perjury, n : -k Si of Licensed Phunber Property Owner Certification l certify that:(1)This dwelling unit is eligible for the imposition on the tenants of a charge for water and/or sewer usage in accordance with the water submetcring law(MGL c.186,§22);(2)All showesheads,faucets,and water closets in this dwelling unit are water conservation devices that meet the standards specified above;(3)The water submeter measuring the use of water in the dwelling unit was installed by a licensed plumber and is in compliance with the standards specified above,or the water meter measuring the use of water in this dwelling unit was installed by a`water company" as defined in M.G.L.c.186,122; (4)The water meter or submeter measures the water usage exclusive to this unit;(5)I 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 faint;(6)That all information included on this certification is true and accurate to the best of my knowledge. S' tinder the pains and penalties of perjury, A � . 0— A�4— essw t o. Print Name of Owner Si acute of Owner "MaTh Date E3 The property has been transferred to owner above and the unit RteOek 2020 remains in com fiance with themquiresmis of M.G.L.c.186 22 Date: by BOH: 'THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INMAYM611)li MMING BOARD OF HEALTH MDPH-CSP Submctering Form,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 far Human Habitation (State Sanitary Code Chapter ED,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 9206 24 Urv/rmw Salem MA Zi Code:01970 M EQUIPMXNT INSTALLATION INFORMATION 105 CMR 410.000 requires the installation of water conservation devices prier to a dwelling unit becoming eligible for the imposition on tenants of a charge for water and/or sewer.The devices must meet the following specifications: i Sbowecbeads with maximum flow rate not to exceed 2'cjallons per minute(2.5 gpm) 1 Faucets with maximum flow rate not to exceed 2 in gallons per minute(22 gpmm) Uhn-tow flush water closets(toilets)not to exceed l m0 gallons per flush(1.6 VQ 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 die water closets and submetering equipment. y Flexible Axis !I Submetering equipment information: Master Meter _— Manufacturer Model# _ w Licensed Plumber Certification Joseph Belleteuille 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[lush. Vet=ined that existing water closets do not exceed 1.6 gallons per flush. The plumbing permit issued by the cRy/town,if required,is attached. ❑Dwelling unit is connecter/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 submater. Signed under the pains and penalties of perjury, Signature of incensed Plumber Property Owner Certification I certify that:(1)This dwelling unit is eligible ror the imposition on the tenants of a charge rer water and/or sewer usage in accordance with the water submetering law(MGL c.186,§22);(2)All showethe ads,faucets,and water closets in this dwelling unit are water conservation devices that meet the standards specified above;(3)The water submeter measuring the use of water in the dwelling unit was installed by a 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 f xm;(6)That all information included an this certification is true and accurate to the best of my knowledge. I&S eelunder the pains and penalties ofperjury, om, t QS4,1 I VED Print Name of Owner Si ature ofOwner Da Date 11c property has been transferred to owner above and the unit Receiver/ FEB 12020 remains in co liance with the uireme nts of M.G.L.c. 186 22 Date: b B4H: *THIS FORM MUST BE FILM WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBMETEF Fffi,OF SALEM BOARD OF HEALTH MDPH-CSP Submakting Form,Rev 11.4-16 MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH SUBMETERING OF WATER AND SEWER CERTIFICATION FORM *In accordance with M.G.L.c.186,122 and 105 CMR 410.000:Minimum Standards of Fitness for Humus Habitation (State Sanitary Code Chapter 11),the following dwelling unit is eligible for the imposition on the tenants of a charge for water and/or sewer service. PROPERTY INFORMATION Address: 4 First Street 9205 19 1101DRIS in hWL 24 city/Town: Salem MA gk Code.-01970 EQUIPMENT INSTALLATION WFORMATZON 105 Clot 410.000 requires the installation of water conservation devices prior to a dwelling unit becoming eligible far the imposition on tenants of a charge for water and/or sewer.The devices must meet the following specifications: Showerheads with maximum flow rate not to exceed 2 4gallons per minute(LS 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 1 duo gallons per flush(1.6 gp1) The submetering equipment used to measure the quantity of water used for each dwelling unit and common area must tweet the standards of accuracy and testing of the American Water Works Association or similar accredited association. A licensed plumber mast install the water closets and submetering equipment. Submetaing equipment infamuation: Master Meter Flexible AXIS Manufacturer Model# Licensed Plumber Certification Joseph Bellefetlllle 9793 12-18 2019 Print Name of Plumber License# Date I certify that(check all that apply): I have installed the submetcring equipment listed above in accordance with accepted plumbing standards. I have installed one or more water closets not exceeding 1.6 gallons per flush. Determined that existing water closets do not exceed 1.6 gallons per flush. The plumbing permit issued by the city/town,if required,is attached Q Dwelling unit is connected directly to a meter installed by a water company and,in accordance with M.G.L.c.186,§22(p),does not require the installation of a submeter. Signed under the pains and penalties of perjury, SiLmstart fLieensed Phonber Properly 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(MOL 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 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 mcas„res 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)11rat all information included on this certification is true and accurate to the best of my knowledge. Signed under the pains and penalties oofpmjwy, tor - Su.� tkJ p Print Name of Owner Signature of Owner R� alb Date 0 The property has been transferred to owner above and the unit Relr 21 2020 remains in con liaace with the mquirements of M.G.L.c. 196,622 Date: b Bo *THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INMATg4rF l Fffi BOARD OF HEALTH MDPH-CSP Submeteft Form,Rev 114-16 MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH SUDNIETERING OF WATER AND SEWER CERTIFICATION FORM *In accordance with M.G.L.c.186,§22 and 105 CMR 410.000:Minimum Standards of Fitness far Human Habitation (State Sanitary Code Chapter I1),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 tj.;t o9204 SnNinift in h1dr •4 ci R'own: Salem MA Zia Code:01970 EQUIPh ;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 andlor sewer.The devices must meet the following specifications; Showerheads with maximum flow rate not to exceed 2 llons per minute(2.5 Spin) Faucets with maximum flow rate not to exceed 2 galIons per minute(2.2 gpm) Ultra-low flush water closets(toilets)not to exceed 1 m°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 submetaiog equipment. Submetering equipment information: Master Meter Flexible Axis Manufacturer Model# Licensed d Plumber Certification _ Joseph Beilefeuiile 9793 12-16 2019 Print Name of Plumber License# Date I certify that(check all that apply): I have installed the submetering equipment listed above in accordance with accepted plumbing standards. I have installed one or more water closets not exceeding 1.6 gallons per flush. Determined that existing water closets do not exceed 1.6 gallons per flush. The plumbing permit issued by the:city/towa,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. 0- Signed under the:pains and penalties of perjury, v SiEnature o Licensed Pher Property Owner Cer0cation f I certify that:(1)This dwelling writ is eligible for the imposition on the tenants of a charge for water andlor sewer usage in accordance with the water submetering law(MGL c. 186,§22);(2)All showenceads,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 compliancawith the standards specified above,or the water meter measuring the use of water in this dwelling unit was installed by a"water company" as defined in M.G.L.c.186.122; (4)The water meter or submeter measures the water usage exclusive to this unit;(5)I will provide to the tenants of this dwelling unit,prior to occupancy,a written rental agreement that clearly 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 true and accurate to the best of my knowledge:. Signed under the pains and penalties of pm jury, exz 4S 3 ftr Print Name of Owner Simrature of Owner t Date The property has been transferred to owner above and the unit � 212020 remains in compliance with the requirements of M.G.L.m 186 22 Date: I!bv Bt *THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATI"Wqffiln BOARD OF HEALTH MDPH-CSP Submeteft Form,Rev 114-16 MASSACHUSE77S DEPARTMENT OF PUBLIC HEALTH SUBMETERING OF WATER AND SEWER CERTIFICATION FORM *In accordance with M.G.L.c.186,§22 and 105 CMR 410.000:Minimum Standards of Fitness for Human Habitation (State Sanitary Code Chapter II),the following dwelling unit is eligible far the imposition at the tenants of a charge for water and/or sewer service. PROPERTY IIVFORrKATION Address: 4 First Street I ya,,4 9203 9 Qf Tinim in h1dor 24 Ci /Town: Salem MA Zip Code.01970 EQUVbW4T INSTALLATION INFORMATION 105 CMR 410.000 requires the installation of water conservation devices prier to a dwelling unit becoming eligible for the imposition on tenants of a charge farwater 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(2.2 gpm) Ultra-low flush water closets(toilets)not to exceed 1010 gallons per Etush(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 Wailes 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 Beilefeuille 9793 12-16-2019 Print Name of Plumber License 0 Date I certify that(check all that apply): I have installed the submetering equipment listed above in accordance with accepted plumbing standards. I have installed one or more water closets not exceeding 1.6 gallons per flush. Determined that existing water closets do not exceed 1.6 gallons per flush. The plumbing permit issued by the cityltown,if required.is attached. ❑Dwelling unit is connected directly to a meter installed by a water company and,in accordance with M.G.L.c.186,§22(p),does not require the installation of a subteter. Signed under the pains and penalties of pcduty, n x Signature a icensed Plumber Property Owner Certification I certify that:(1)This dwelling unit is eligible for the imposition on the tenants of a charge for water and/or sewer usage in accordance with the water submetering law(MGL c. 186,§22);(2)All showerheads,faucets,and wane 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 it 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 pcdury,q.3 Aa, \�V C L D Print Name of Owner enature of Owner D Date l7 The property has been transferred to owner above and the unit Received FEB 21 2020 remains in c❑r liance with the reQuirtrnents of M.G.L.c. 186 22 Date: -k BOH: "THIS FORM MUST BE FILED MnTH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBMETE OF SALEM BOARD OF HEALTH MDPH-CSP Submctering Form,Rev i IA-16 MASSACHUSETPS 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 fallowing dwelling unit is eligible for the imposition at the tenants of a charge for water and/orsewer service. PROPERTY INFORMATION Addresx 4 First Street Lrnir#9202 24 IPawn: Salem MA Zip de:01970 EQ1UIPb1XNT INSTALLATION INFORMATION 105 CMR 410.000 requires the installation ofwater conservation devices prior to a dwelling unit becoming eligible for the imposition on tenants of a charge for water and/or sewer_The devices must meet the fallowing specifications: Showerheads with maximum flow rate not to exceed 2:jallous 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 Ito 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. Submeteting equipment information: Master Meter Flexible Axis Manufacturer Model# Licensed Plumber Certification _ Joseph Sellefeuille 9793 12-16-2019 � Not Name of Plumber License# Date I certify that(check all that apply): have installed the submetering equipment listed above in accordance with accepted plumbing standards. I have installed one or more water closets not exceeding 1.6 gallons per flush. Determined that existing water closets do not exceed 1.6 gallons per flush. The plumbing permit issued by the city/town,if required,is attached I ❑Dwelling unit is connected dirccUy 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, � i.,(�, � _ Sienature 6f Licensed Pkimber Property Owner Certification I cert4 flat:(1)This dwelling unit is eligible for the imposition on the tenants of a charge for water mWor sewer usage in accordance with the water submetcring law(MGL c.186,§2.2);(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 unit was installed by a licensed plumber and is in compliance with the standards specified above,or the water meter measttring 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)'Chat all information included on this certification is true and accurate to the best of my knowledge. Signed under the pains and penalties of perjury, Print Name of Owner Signature of Owner lira E Date 0 tr The property has been ansferred to owner above and the unit Received FEB 21 : 020 retrains in compliance with the uiremeruts of M.G.L.c. 186, 22 _ Date: b BOH: _ *THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUB1Utffbr�SALEM BOARD OF HEALTH MDPH-CSP 5ubmetering Form,lieu 11 at-16 MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH SUBM ETERING OF WATER AND SEWER CERTIFICATION FORM "In accordance with M.G.L.c.186,§22 and 105 CMR 410.000:Minimum Standards of Fitness for Human Habitation (State Sanitary Code Chapter 11),the f Bowing dwelling unit is eligible for the water and/or sewer service. gi imposition on the tenants of a charge for PROPERTY INFORMATION 4 Flrst Street 9201 24 it LkLwa Ci /Town; Salem ::I MA Zi Code:01970 EQO1Pi1MNTINSTALLilLTION WFORMATZON 105 CMR410.000 requires the installation of water conservation devices prior to a dwelling unit becoming eligible for the imposition on tenants Of fit charge for water and/or sewer.The devices must meet the following specifications: Showerheads with maximum flow rate not to exceed 2�Mtons per minute(2.5 gpm) Faucets with maximum How rate not to exceed 2 gallons per minute(2.2 am) Ultra-low Hush water closets(toilets)not to exceed 1&10 gallons per push(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 plumbs must install the water closets and submetering equipmenL Submetering equipment information: Master Meter Flexible Axis -- *turer Model# Licensed Plumber Cerdilcrika .lMPh Belleteuille 9793 12-16-2019 Print Name of Plumber Date 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,ifmquited,is attached, ❑Dwelling unit is connected directly to a meter,installed by a water cangiany and,in accordeacc with M.G.E..c 186,§22(p),does not requue the installation of a submeter. Signed under the pains and penalties of perjury, �orce, nsed hunter Property Owner Certification 1 eertifY 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, closets in this re faucets,and water dwelling unit a water conservation devices that meet the standards specified above;(3)The water water c measuring the use of water in the dwelling unit was installed by a licensed plumber and is is Compliance with the standards spci fled above,or the water meter measuring the use of water in this dwelling unit was installed by a'wvater company" as defined in M.G.L.c.186, 122; (4)The water meter or submeter measures the water usage exclusive to this unit;(5}I will provide the tenants of this dwelling unit,prior to occupancy, written rental agreement that clearly provides for the separate chargigi ng 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. Si ed under the pains and penalties of perjury. Print Flame of Owner Signature of Owner The property has been transfenvd to owner above and the unit Date Received r in Banta with the uirements of M.G_L.r- 186 22 Date: O : FEB 21 020 'THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING U8 M"W SALEM MDPH-CSP Submataft 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.136,9 22 and 105 CMR 410.000:Minimum Standards of Fits for Human 13abitation {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. PROPIERTY INFORMATION — I Address: 4 Flrst Street • 9108 7bmamingeligibla 4 own: Salem MA 70 105 CMR 410.000 EQURMNT INSTALLATION INFORMATION requires the installation of water conservation devices prior to a dwelling eligible for the imposition oa tenants ofa charge for water and/or sewer.The devices must meet the followons:Sbowerheads with maximum flow rate not to exceed2 xalloas per minute(2 5 gFaucets wiW marcinwat flawtate not to exceed 2 7'1 gallons per minute(22Ultra low flush water closets(toilets)not to exceed 1 d14 gallons per Flush(l.6 gThe submetering equipment used to measure the quantity ofwater used for each dwelling un area must tweet the standards of accuracy and testing of the American Water Worlrs Association or similar accredited association. A licensed plumber must install the water closets and submetaing equipment. Submetering equipment information: Master Meter Flexible Axis -- Manufacturer ��Model# Licensed Plumber Ceriifleatlon - Jaseptt Belleftluille _ 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 gailous per flush. Ile plumbing permit issued by the city/town,ifr+equired,is attached. ❑Dwelling unit is connected directly to a meter installed by a water company gad,in accordance with M.G.L.c. 186,122(p),does not require the installation of a submeter. Signed under the pains and penalties of perjury, -� h� races �„LQ -- " Si¢natureof Licensed Plmtt er Property Owner Certilleattoa I certify that:(l)This dwelling unit is eligible for the imposition on the tenants ofa charge For water and/or sewer usage J in accordance with the water submctering 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 watersubmeter 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 io M.G.L.c.186,§22; (4)The water meter or submeter measures the water usage exclusive to this unit;(S)1 will provide to the tenants of this dwelling unit,prior to occupancy,a written rental agreement that cienriy provides for the separate charging of water and/or server service,and a copy of this certification form;{Sj That all tnfom�ratpr included th this certification is true and accurate to the best of my knowledge, on Si ed under the pains end penalties of perjury, qs t gat A � 'bw csr Print Name of Owner Signature of Owner L ❑ Date The PropcnY h�beat hansferred to owner above and the unit xeceiv6 21 2020 remains in con hence with the airements of M.G.L.c. 186 22 Date: gp *THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INl17ATlNG IgERtNG EM MDPH-CSP SubmrteringForm,Rev 11-4-16 BOARD OF HEALTH MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH SUBMETERWG 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 Humor Habitation (Slats Sanitary Code Chapter II),the fallowing dwelling unit is eligible for the imposition on the tenants of a charge for water andlar sewer service. PROPERTY INFORMATION rA" , First Street - 9107 24 Salem14tAZi Code:01970 10.000 EQ1 IPMNT IN 'r111ATION INFORMATION requires the installation of water conservation devices prior to a dwelling unit becoming eligible for the on tenants of a charge for water sadior sewer.The devices must meet the following specifications: s with maximum flow rate not to exceed 2�allons per minute(2.5 gpm) h maximum flow rate not to exceed 2 zwgallons per minute(2.2 gpm) tra-ow flush water closets(toilets)not to exceed 1 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 jAr mation: Master Meter Flexible Axis Manufacnutx 7standardL i fceaaW Plumber Certiticatfoa Joseph Bellefeulile 9793 Print Name of Plumber — -—- License#1 certify that(check all that apply):have installed the submetering equipment listed above in accordance with accepted plumbi I have installed acre or more water closets not exceeding 1.6 gallons per flush. Determined that existing water closets do not exceed 1.6 gallons per flush. The plumbing permit issued by the cityltown,if required,is attached. ❑Dwelling unit is connected directly to a meter installed by a water company and.in accordance with M.G.L.c. 186,§22(p),does not require the installation of a submeter. Signed under the pains and penalties of perjury, Si store ofj icensed Plumber Property Owner Certification I certifjr that;(1)This dwelling unit is eligible for the imposidan on the tenants ofa charge for water and/or sewer usage in accordance with the water submeteriag law(MGL c. 186,122);(2)All showerlteads,faucets,and water closets in this dwelling unit ate water conservation devices that mod 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 otwater 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 writ;(5}1 will Pmvidc 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 this certification is true and accurate to tic best army knowledge. (�That all infomiati°t'included an Signed under the pains and penalties of perjury, 4 a I C- A Print Name of Owner Si atrrre of Owner iv t0tc�p��erty has been ttansfemd to owner above and Ilse unit Date iwin Treace wits the Ra r�ttirameats of M.G.L,c. 186 ZZ Date: b BeOj EB 21 2020 iv -THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING GRSALEM DPH-CSP Submetering Form,Rev I1-4-16 BOAS tRTDoOFF HEALTH M 1TY MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH SUBhMTERING OF WATER AND SEWER CERTIFICATION FORM "In accordance with M.G.L.c.186,§22 and 105 CM 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 tettan�of a charge far water and/or sewer service. PROPERTI(INFOR1NAiZON Address: 4 First Street 9106 24 Ci frown.- Salem MA Zi Code:01970 EQDIPMENT INSTALLATION INFORMATION 105 CMR 410.000 requim the installation of water conservation devices prior to a dwelling unit becoming eligible for the imposition om tenants of a charge for water and/or sewer.The devices must meet the following specifications: Sboworbeads with maximum flow rate not to exceed 2'meons 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 dms gallons per flush(1.6 gpt) The submetering equipment used to measure the quantity of water used for each dwelling unit and common area must meet the standards of accuracy and testing of the American Water Works Association or similar accredited association. A licensed plumber must install the water closets and submetering equipment. Submetering equipment information: _ Master Meter Flexible Axis Manufiteturer Model# Licensed Plumber Certification Jtase h BallefeU111e 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 slush. Determined that existing water closets do not emceed 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. IN,§22(p).does not require the installation of a submeter. Signed under the pains and penalties of - - Si tune of i�edgr Properly 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 m accordatmcc with the water sulsmctcrimg 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 wafer in the dwelling unit was installed by a licensed plumber and is in compliance with the standards speci tied 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 ckarly 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 pcgtuy AV- Print Name of Owner Si nature ofQwner m �: VED Date The property has been transferred to owner above and tits unit Received reRmeins in /saner with the m»rematts of M.G.L.0:.186, _Date: r$oH: FEB 21 2020 "THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBMETfN CITY%F SALEM MDPH-CSP Subrrukring Form,Rev 11-4-16 BOARD OF HEALTH MASSACRUSETTS DEPARTMENT OF PUBLIC HEALTH SUBMETERING OF WATER AND SEWER CERTIFICATION FORM `Its accordance with M.G.L.c.186,§22 and 105 CMR 4I0.000:Minimum Standards of Fitness for Human Habitation (State Sanitary Code Chapter III the following dwelling unit is eligible for the imposition on the tenants of a water and/or sewer service. ---1'AOPIBRT'Y i1VFORMATION charge for — - ��" Address: 4 First Street :9105 A Zy /rower: Salem MA ai Code:01970 EQ NTINSTALLATIONINFORMA17ON 105 CMR 410.000 requires the installation ofwater conservation devices prior to a dwelling unit becoming eligible for the imposition on tenants of a charge for water and/or sewer.The devices must meet the following specifications: Showetheads with maximum flow rate not to exceed 2%falcons per minute(2.5 gpm) Faucets with maximum flow rate not to exceed 22" gallons per minute(2.2 gpm) Ultra-low flush water closers(toilets)not to exceed Isla gallons per flush(1.6 gpf) The submtetering 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 simr'iaraccredited association. A licensed plumber must install the water closets and submetering equipment. Submetering equipment information: Master Meter _ Flexible Axis Manufacturer Model# Lfceased Plumber Certification Jtmph Belleteunie 9793 12-18 2019 Print Name of Plumber - License# N tify I cer that(check all that apply); tc 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 push. 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 conmected directly to a meter installed by a water company and,in accordance wills M.G.L.c.186,§22(p),does not require the installation of a su er Signed under the pains and penalties of perjury, f, Si 31atum f Licensed Phatiber Property Owner Certification [dI ify that:(1)This dwelling unit is eligible for the imposition on the tenants of a charge for water and/or sewer usage cordance with the water submctering law(MGL c. 186,§22);(2)All showenc�ads,faucets,and water closcl9 in this ing unit am water conservation devices that meet the standards specified above;(3)The water submater measuring se of water in the dwelling unit was installed by a licensed plumber and is in compliance with the standards fied above,or the water meter measuring the use ofwater in this dwelling unit was installed by a"watercorrrparyfined in M.G.L.c.186,§22; (4)The water motor or submeter measures the water usage exclusive to thisunit;(rovide to the tenants of this dwelling wait,prior to occupancy,a written maw agreement that clearly provides for the ate charging of water and/or sewer service,and a copy of this certification form;(6)That all infomution included on this certification is true and accurate to the best of my knowledge. Signed under the pains and penalties ofperjuty, gw rug f�� dww� Print Name of Owner Siena of Owner C7 The Property has been transferred to owner above and the unit Date tensaias in /canoe with the uirements of M.G.L.c. 186 22 Date: lteby ce 21 2020 *THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATIN WWWRm MDPH-CSPSubmcteringForm,Rw 11.4-16 BOARD OF HEALTH M1ASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH SUBMETEMC 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 Rumm Habitation (State Sanitary Code Chapter III 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 t • 9104 24 Cirvfrown• Salem MA Zi code:01970 EQI�MIINT INSTALLATIONINFORI 17ON 105 CMR 410.000 requires the insWlettion of water conservation devices prior to a dwelling unit becoming eligible for the imposition on tenants of a charge for water and/or sewer.The devices must meet the fallowing specifications: Showerbeads with maximum flow rate not to exceed 2 x§allaas per minute(2.5 gpm) Faucets with maximum now rate not to exceed 2 n gallons per minute(2.2 gpto) Ultra-low flush water closets(toilets)not to exceed 1610 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 meat 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 Jot;eplt Bellefeuille 9793 12-16 2019 Print Name of Plumber - — License# Date I certify that(check all that apply): I have installed the submetering equipment listed above in accordance with accepted plumbing standards. Lj 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 eityAown,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, . — — �Sisaof Licensed Phan er Property Owner Certification [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)AA showerheads,faucets,and water closets in this dwelling unit ate water conservation devices that meet the standards specified above;(3)The water submeter measuring the use of water in the dwelling unit was installed by a licensed plumber and is in compliance with the standards specified above,or the water meter measuring the use of water in this dwelling unit was installed by a"water company" as defined in M.G.L.c.186,§22; (4)The water meter or 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 separate charging of water and/or sewer service,and a copy of this certification fo aProvides for the this certification is true and accurate to the best of my knowledge. �'(�That all information included an Signed under the pains and penalties of perjury, Print Name of Owner Si store of Owner ate The:property has been transferred to owner above and the unit Date Rece�� 21 2020 remains le con dance with the requirements of M.G.L.c.18b 22 Date: by BOH: *THIS FORM MUST BE FILED 1NiTH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATINeSCtflI W81I111fiM BOARD OF HEALTH MDPH-CSP Subau:tering Focar,Kw11.4-16 BWSACEUSETTS DEPARTMENT OF PUBLIC HEALTH SUBMETEMG OF WATER AND SEWER CERTIFICATION FORM 'In accordance with M.G.L.c.196,622 and 105 CMR 410.000:Minimum Standards of Fitness far Hunan Habitation {State Sanitary Code Chapter IJ),the fallowing dwelling unit is eligible for the imposition on the tenants ofa change far water and/or sewer service. PROPERTY INFORMATION Address: 4 First Street 9103 a nfumirs iln hidv 24 Ci ri'own• Salem MA Zi Code:01970 E4�1V�1T INSTALLATION DYFORMA,TION 105 CMR 410.000 requires the installation of water conservation devices prior to a dwdling unit becoming eligible for the imposition as tenants ofa charge far water and/or sewer.The devices must meet the following Spec cation Sbowerheads with maximum flow rate not to exceed 2�11ons per minute(2.5 Spin) Faucets with maximum flow rate not to exceed 2 gallons per minute{2.2 gpm) Ultra-low flush water closet;(toilets)not to exceed 1 ew 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 infomtation: Master Meter Flexible Axis Masufactuter Model# Licensed Plumber Certification .ioseph Beltefeuille 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 push. Determined that existing water closets do not exceed 1.6 gallons per flush. The plumbing permit issued by the cityhown,ifrequired,is attached. ❑Dwelling unit is connected directly to a meter installed by a water company and,in accordance with M.G.L.c. 186,122(p),does not require the installation ofa submeter. Signed under the pains and penalties of perjury, -t Bitola f L icamsed Phanber Property Owner certification I certify that:(1)This dwelling unit is eligible for the imposition an the tenants ofa charge for water and/or sewer usage in accordance with the water subumtering law(MOL c.186,§nX(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.186,6 22; (4)The water meter or submcter measum the water usagc 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 afwaterand/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. Sighed under the pains and penalties ofpctjury, � 4 � Qr..i� 1 ( �i Print Name of 0woer Si tare of Owner e C]The propetty has been transferred to owner above and the unit �Dalwe ivedCrerasins in ca Hance with the uiremenis of M.G.L.c. 186 22 Date: OH: 020 "THIS FORM MUST BE FILED WITH Tllt:kOCAL BOARD OF HEALTH PRIOR TO INMATIN15 SUBMETERIND MDPH-CSP 5ubnwWdngForm,Rev 11-4-16 CITY OF SALEM BOARD OF HEALTH MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH SUBMETERFNG 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 1I),the following dwelling unit is eligible for the imposition ern the tenants of a charge far water and/or sewer servicerphunber PROPERTY INFORMATION s: 4 First Street g102 24 own: Salem MA zi code:01970 Ral0.000 EQ�h 'INSTALLATION DWORhjf T—jON tion on tenants of a charge for water andtoon rsewer The devicesmeet the folio conservation devices prior to a dwelling unit for We L heads with maximum flow rate not to exceed 2 Uallons per minute(2.5 gpm)with maximum flow rate not to exceed 2 gallons per minute(2.2 Spin) w flush water closet(toilets)not to exceed l ea gallons per flush(t.6 gpf) metering equipment used to measure the quantity of water used for each dwelling unit and common arts must e standards of accuracy and testing of the American Water Works Association or similar accredited association. ed plumber must install the water closets and submetering equipment. Submetering equipment information: Master Meter Flexible Axis --- —� Manufacturer Model# Licensed Plumber CertiBeailon Joseph Bellefeuille_ 9793 12-16 2019 Print Name of Plumber License d ~" Date FfDammined eck all that apply):led the submeteriag equipment fisted above in accordance kith accepted plumbing standards. lled one or more water closets not exceeding 1.6 gallons per flush. that existing water closets do not exceed 1.6 gallons per flush. g permit issued by the cityhown,ifrequired,is attached ❑Dwelling unit is connected directly to a meter installed by a water company and,in accordance with M.G.L.c.186,§22(p),does not require the installation of a submeter. Signed under the pains and penalties of perjury, fi T"" `` Sitanatuio of Licensed Plumber Property Owner CertMcation I certify that:(1)This dwelling unit is eligible for the imposition on the tenants of a charge fisr water and/or sewer usage in accadancc with the water submetering law(MGL c. 186,§22);(2)Aft 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 as defined in M.G.L.c. 186,§22; (4)The water meter or submeter measures the water will provide to the tenants of this dwelling unit,prior to occu en that C u to this unit,or I Grate c PAY►a written rents!agreement that clearly provides for the separate hanging 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 pcdwy, e , as 1Ll1��,�;— �1�-- Print Name of Owtux Signature of OwnerDate D C]Tbc P��y has baau transferred to owner above and the unit Received remains m cam Rance with the requirements of M.G.L.a 186 22 Date: b BoH:FEB 21 2020"THIS FORM MUS BE FlLEO 1Mfli THE LOCAL BOARD OF HEALTH PRIOR TO INITIATING SUBMETERiNG MDPH-CSPSubmeteringForm,(rev 114-16 CITY OF SALEM BOARD OF HEALTH MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH SUBMIXTERING OF WAFER AND SEWER CERTIFICATION FORM *In accordance with M.G.L.c.186,§22 and 105 CMR 4I0.000:Minimum Standards of Fitness far Human Habitation (State Sanitary Code Chapter 11),the fnlbwing 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 9901 24 Ci /Town: Salem MA Zi Code.01970 EQ 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 specifications: Showerbeeds with maximum flow rate not to exceed 2+s alIons per minute(2.5 spin) Faucets with maximum flow rate not to exceed 2"i gallons per minute(2.2 gpm) Ultra-low flush water closets(toilets)not to exceed I Me 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 meet the standards of accuracy and testing of the American Water Wodm Association or simu'laraecredited association. A Iicenssed plumber must install the water closets and submetering equipment. Submetering equipment infam ation: Master Meter Flexible Axis Manufacturer Model 6 Licensed Plumber Certification Joseph Behefettille 9793 _ 12-16-2019 Print Name of Plumtber License# Date f1bbaveeminsmIliled fy that(check all that apply): av lled the submetering equipment listed above in accordance with aexepted plumbing standards.one or more water closets not exceeding I.6 gallons per flush. termined that existing water closets do not exceed 1.6 gallons per flush. e plumbing permit issued by the cityhown,if required,is attached. ❑Dwelling unit is connected directly to a ureter installed by a water company and.in accordance with - M.G.L.c.186,122(p),does not require the installation of submeter. Signed under the pains and penalties of perjury. P S' of Licensed Phnnber Property Owner Cerrilleation I certify that:(1)This dwelling unit is eligible for the imposition on the tenants of a charge far water and/or sewer usage in accordance with the water submetering law(MGL c. 186,§22);(2)All showertxcads,faucets,and water closets in this dwelling twit 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 sta to unit; S) ndards specified above,or the water meter measuring the use of water in this dwelling unit was installed by a'water company" as defined is M.G.L.c. 196,§22; (4)The water meter or submeter measures the water usage exclusive this ( I will provide to the tenants of this dwelling unit,prior to occupancy,a written rental agreement that clearly provider 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 brae and accurate to the best of my knowledge. Signed under the pains and penalties ofpcdwy, ses•• i z A 6 tt� Print Name of Owner l~ Si�ttnattre of Owner �Received The property leas been transferred to owner above and the unit remains in liance with the requirements of M.G.L.c. 186 22 Date: "THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO 1NMAMNG SUBMEfERING MDPH-CSP Submctct%g Form,Rev 11.4-16 CITY OF SALEM BOARD OF HEALTH MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH SUBMETEN NG OF WATER AND SEWER CERTIFICATION FORM *In accordance with M.G.L.c.186,§22 and 105 CMR 410.000.Minimum Standards of Fitness for Human Habitation (State Sanitary Code Chapter II),the following dwelling unit is eligible for the imposition on the ten of a cbazge for water and/or sewer service. • PROPERTY INFORMATION [Address: 4 First Streeti frown: Salem MA Zip Code;01970 EQUIp14113NT INSTALLATION INFORMATION 105 CMR 410.000 requires the installation of water conservation devices prim to a dwelling unit becoming eligible for the imposition on tenants ofa charge for water and/or sewer.The devices must meet the following specifications; Showerheada with maximum flow rate not to exceed 2 x"gallons per minute(2.5 gpm) Faucets with maximum flow rate not to exceed 2 gallons per minute(2 2 gpm) Ultra-low flush water closets(toilets)not to exceed 1'910 gallons per flush(f.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 Wodcs 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>Y Licensed Plumber Cerlitfeatlon Joseph Belleteuilie _ _ 9793 12-16-2019 Print Name of Plumber T License# — Date I certify that(check all that apply): M have installed the submetering equipment listed above in accordance with accepted plumbing standards. I have installed one or more water closets not exceeding 1.6 gallons per flush. Determined that existing water closets do not exceed 1.6 gallons per Flush. The plumbing permit issued by the cityAown,if repaired,is attached. ❑Dwelling unit is connected directly to a meta 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, n - ---- $' mtureof lCgt,SedPlmds{bCr Property Owner Certifleadoa I certify that:(1)7bis dwelling unit is eligible for the imposition on the tenants ofa charge for water and/or sewer usage in accordance with the water submetering law(MGL c.186,§22).(2)All showerheads,faucets,and water closets in this dwelling unit are water conservation devices that meet the standards specified above;(3)7be water submeler measuring the use of water in the dwelling unit was installed by a licensed plumber and is in compliance with the standards specified above,or the water meter measuring the use of water in this dwelling unit was installed by a"water cmmr�rmy" as defined in M.G.L.c.186,§22; (4)77re water meter or submeter measures the water usage exclusive m this unit;(5)I Will provide to the tenants of this dwelling unit,prior to occupancy,a written rental agroemcat that clearly provides for the separate charging of water and/or sewer service,and a copy of this certification fomr;(6)That all information included on this certification is true mad accurate to the best of my knowledge. Signed under the pains and penalties ofperjury, rZ,- 1� ct g It Print Name of Owner Si ature of Owner 76c prop bas been transfetmzd to owner above and the unit ReceDa remains in Hance with the reanirerrments of M.G.L C. 186 22 Date: ived *THIS FORM MUST BE FILED WITH THE LOCAL 130ARD OF HEALTH PRIOR TO INITIATING SUBMEfERING MDPH-CSP Submetering Form,Rev 11-4-16 CITY OF SALEM BOARD OF HEALTH MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH SUBMETERING OF WATER AND SEWER CERTMCATION FORM `In accordance with M.G.L.c. 196,122 and 105 CMR 410.000.Minimum Staadat�of 1:�For Human Habitation (State Sanitary Code Chapter In,the 6ollowiag dwelling unit is cligi'ble for the imposition an the tenants of a charge far water and/or sewer service. PROPERTY INFORMATION rFaucetswith : 4 First Street 900$ 24 n: Salem MA zi Code:01970 R41a000 EQ NTINSTALLATIONDWORMA17ON requiros the installation of water conservation devices prior to a dwelling unit becoming eligible for tie on on tenants of a charge far water and/or sewer.The devices must meet the fallowing specificahoas: eads with maximum flow rate not to exceed 2�all'ans per minute(2.5 gpm) with maximum flow rate not to exceed 2 gallons per minute(2.2 Spin) flush water closets(toilets)not to exceed l&1°gallons per flush(t.6 gpf) etering equipment users to measure the quantity,of water used for each dwelling unit and common area must standards of accuracy and testing ofthe American Water'Wodm Association at similar accr muext association. A licensed plumber must install the water closets and submetering equipment. Submeteriag equipment informadon: Master Meter Flexible Axis °1'f11Ct11 Model# Licensed Plumber Certdfle adou Joseph 8e11eleuille 9793 12-16-2019 Print Name of Plumber License 6 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 rerqusred,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 ofs submete r. Signed under the pains and penalties of pedtiry, )�4 47 Sienature o icensed P Property Owner Certtf eWon 1 certify that:(I)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 wear in this dwelling unit was installed by a"water company" as defined in M.G.L.c. 186,122; (4)The water meter or submeter measures the water usage exclusive to this unit;(5)I Will pmvide 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 roan;(6)That all information included on this certification is title and accurate to the best of my knowledge. Signed under the pains and penalties of pci ury, Print Name orowner S' lure ofOwner ' Date The property has been ttansfemd to owner above and the unit Rsceiv remains is liauce with the uireittents of M.G.L.c. 186 22 Date_ Hfl B 21 2020 IT *THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO tNiT1Al1NG St18Mly CITY WEM MDPH-CS?SubmctrcingFocm,Rev 114-16 BOARD OF HEALTH MASSACSUSETTS DEPARTMENT OF PUBLIC REALTI3 SUBMETERING OF WATER AND SEWER CERTWICATION FORM *In accordance with M.G.L.r~186,§22 and 105 CMR 410.000:Minimum Standards of Fitness for Humuu Habitation (State Sanitary Code Chapter II),the Following dwelling omit is eligible for the imposition water and/or sewe service. the ftaft of a charge for PROPERTY INFORMATION Address; 4 First Street 9004 Ci own: Salem EQUn%=NT INSTALLATION INFORMATION-Zi Code:01970 105 CML;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 fbllawing specifications: Showerheads with maximum flow rate not to exceed s Faucets with maximum flow rate not to exceed 2 7" gallons per rmnminute(2.5 gpm) Ultra-low flush water closets(toilets)not to exceed i Otto gallons per minute.6 g f) gallons per Flush(l.6 gpt) meet the submetering meteri de��ip�used to measure the quantity of water used for each dwelling unit and common area must accuracy and testing of the American Water Woxks Association or similar accredited association. A licensed plumber must install the water closets and submetering equipment. Submetering equipment information: Master Meter Flexible Axis Manufacnuer Model# Licensed Plumber Certiflcatlon Joseph Be!leftau!!le_ 9793 Print me Na of Plumber - — 12-1$2019 I certify (check all that a License# Date thath ( PP1Y)� have installed We 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 e P�water closets do not exceed 1.6 gallons per flush. by the city/town,if required,is attached ❑Dwelling unit is connected directly to a meter installed by a water company and,in accordance with M.G.L.c.196,§22(p),does not require the installation of a submeter. Signed under the pains and penalties of perjury, - v Si tum Licensed Phanber Property Owner Certification l certify that:(1)This dwelling unit is eligible for the imposition on the tenants of a charge for water and/or sewer usage in accordance with the water submetering law(MGL c.186,§22);(2)An showerheads,faucets,and water closets in this dwellingumit 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 fiance ed by a"water company as defined in M.G.L.c.186,122; (4)The water meter or submeter measures the water ante e. exclusive to this unit;(5)1 will provide to the tenants of this dwelling unit,prior to occupancy,a written rental separate charging orwater and/or sewer usage servi mud a agreement that clearly provides for the this certification is true and accurate to the bast of my knowledge, certification form'(�That an information included on Signed under the pains and penalties ofperjury, �r. I A Print Name of Owner Y Sieruatuu�e of Owner The Property has been transferred to owner above and the unit D e ruins in lience with the reouireauants of M.G.L.c. 184 Z2 Date: Received *THIS FARM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITlATI G BRA EKING MDPH-CSPSubmetmingForaa,Rev 11-4-16 CITY OF SALEM BOARD OF HEALTH MASSACHUSETTS DEPARTMIENT OF PUBLIC HEALTH SUBMETZMG OF WATER AND SEWER CERTYFICA77ON FORM *In accordance with M.G.L.c.186,§22 and lay CMR 41 OA0a:Minimum Standards of Fitness for Humm Habitation (State Sanitary Code Chapter III the following dwelling unit is eligible for the imposition an the tenants of a charge for water andforsewer service. PROPERTY INFORMATION Address: 4 First Sheet 9002 am in hm, 24 Ci /Town. Salem MA Z" Code:01970 1a5 CMR 410.000 requires EQ NT INSTALLATION INFORMATION quires the installation of water conservation devices prior to a dwelling unit becoming eligible for The imposition on tenants of a charge for water and/or sewer.The devices must meet the following specifications: Sbowerheads with maximum flow rate not to exceed 2�allons per minute(2.5 gpm) Faucets with maximum flow rate not to exceed 2 gallons per minute(22 gpm) Ultra-low flush water closets(toilets)not to exceed 1 fif co gallons per flush(1.6 gpf) The submetering equipment used 10 measure the quantity of water used for each dwelling unit and common area must meet the standards of accuracy and testing of the American Water Wodcs Association or similar accredited association. A Icensed plumber must install the water closets and submetering equipment. Submetering equipment information: Master Meter Flexible Axis Manufacttuer Model# Licensed Plumber Certification Joseph 8e11e1emille 9793 12-162019 Print Name of Plumber License# Data I ctxtify 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 flusb. Determined that existing water closets do not exceed 1.6 gallons per flush. The plumbing permit issued by the chy/town,if required,is attached. ❑Dwelling unit is connected directly to a meter installed by a water company and,is accordance with M.G.L.c. 186,§22(p),does not require the installation of a submeter. Signed under the pains and penalties of perjury, , Sitrnattut of Li' Plumber Property Owner Certification I certifj+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 submatcring law(MGL c.186,§22);(2)All sbowerheads,faucets,and water closets in this dwelling unit are water conservation devices that meet the standards specified above;(3)7be water submeter measuring the use of water in the dwelling unit was installed by a licensed plumber and is in compliance with the standards specified above,or the water meter measuring the use of water in this dwelling unit was installed by a"water company" as defined in M.G.L.c.186,§22; (4)The water meter or submeter measures the water usage exclusive to this unit;(5)I 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 farm;(6)That all information included on this certification is true and accurate to the best of my knowledge. Signed tinder the pains and penalties ofperjury, as 1zt61C, 'Print Name of Owner SionaMm of Owner El Da L_ The property has been transferred to owner above and the unit Received remains is cornpliance with the Mguhaments of M.G.L.c. 186 22 Date: 1by BO . *THIS FORM MUST BE FILED WITH THE LOCAL HOARD OF HEALTH PRIOR TO INITIATING S 1 MDPH-CSPSubmctezing Form,Rev 11.4-16 CITY OF SALEM BOARD OF HEALTH