6 ECLIPSE LANE, UNIT 182A - WATER SUBMETERING CERTIFICATE i�aciUUt�a.ti V UL' 1 1 U lIL`1 t1A 11!'1L1\1 yr r UDL1l..IMAL In
SUBMETERING OF WATER AND SEWER CERTIFICATION FORM
*In accordance with M.G.L.c. 186, §22 and 105 CMR 410.000: Minimum Standards of Fitness for Human Habitation
(State Sanitary Code Chapter II),the following dwelling unit is eligible for the imposition on the tenants of a charge for
water and/or sewer service. _
PROPERTY INFORMATION
Address:6 Eclipse Lane Unit#182A #Of units in bldg. l
City/Town: Salem MA Zip Code: 01970
EQUIPMENT INSTALLATION INFORMATION
105 CMR 410.000 requires the installation of water conservation devices prior to a dwelling unit becoming eligible for the
imposition on tenants of a charge for water and/or sewer.The devices must meet the following specifications:
Showerheads with maximum flow rate not to exceed 2 h gallons per minute(2.5 gpm)
Faucets with maximum flow rate not to exceed 2 2`10 gallons per minute(2.2 gpm)
Ultra-low flush water closets(toilets)not to exceed 1 6110 gallons per flush(1.6 gpf)
The submetering equipment used to measure the quantity of water used for each dwelling unit and common area must
meet the standards of accuracy and testing of the American Water Works Association or similar accredited association.
A licensed plumber must install the water closets and submetering equipment.
Submetering equipment information: _ �' (1,C' r
T-:2-C9__
Manufacturer Model#
Licensed Plumber Certification
C: /
Print Name of Plumber License# fDate
I certify that(check all that apply):
nI have installed the submetering equipment listed above in accordance with accepted plumbin standards.
I have installed one or more water closets not exceeding 1.6 gallons per flush. 6 K!.0111A "
[netermined that existing water closets do not exceed 1.6 gallons per flush.
n The plumbing permit issued by the city/town,if required, is attached. 6tn^ l �� '
(welling unit is connected directly to a meter installed by a water com and,in accordance with
M.G.L .c. 186, § 22(p),does not require the installation of a submet K�__
igned under the pains and penalties of perjury,
of Licensed Plumber
Property Owner Certification
I certify that:(1)This dwelling unit is eligible for the imposition on the tenants of a charge for water and/or sewer usage
in accordance with the water submetering law(MGL c. 186, §22);(2)All showerheads,faucets,and water closets in this
dwelling unit are water conservation devices that meet the standards specified above;(3)The water submeter measuring
the use of water in the dwelling unit was installed by a licensed plumber and is in compliance with the standards
specified above,or the water meter measuring the use of water in this dwelling unit was installed by a"water company"
as defined in M.G.L.c. 186, § 22; (4)The water meter or submeter measures the water usage exclusive to this unit; (5)I
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,
M.Akselrod 08/22/2022
Print Name of Owner Signature of Owner_ Date
Date
The property has been transferred to owner above and the unit • Submitted
remains in compliance with the requirements of M.G.L.c. 186, §22 Date: to BOH:
*THIS FORM MUST BE FILED WITH THE LOCAL BOARD OF HEALTH PRIOR TO INITIATINt O I V LE p
MDPH-CSP Submetering Form Rev. 11.8.2021.docx AUG 2 2 2022
CITY OF SALEM
BOARD OF HEALTH