97 Certification Form 2009 MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH
SUBMETERING OF WATER AND SEWER CERTIFICATION FORM
In accordance with M.G.L.c. 186. § 22 and 105 Cv(R 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 andior sewer service.
Address
`77 5&7¢ s
fI -IL.
PROPERTY INFORMATION
Init4 g Of units in bldg.
®/( ht't MA Zip Code: C' J/
QUIPMENT INSTALLATION INFORMATION
105 CMR 410.000 requires the installation of water conservation devices prior to a dwelling unit becoming eligible for the
'I imposition on tenants of a charge for water and,/or sewer.The devices must meet the following specifications:
City/Town:
I Showerheads with maximum now rate not to exceed 2 gaii(MS per i iJ mm rex,gpul)
Faucets with maximum flow rate not to exceed 2 " ° gallons per minute(2.2 gpm)
Ultra low flush water closets(toilets)not to exceed I s10 gallons per flush (1.6 gpn
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 tpring of the A meriran Water Wnrks Aesnriafinn nr similar accredited association_
A licensed plumber must install the water closets and submetering equipment �/�
Submetering equipment information: ei'ilc';(el�ey /'l2.6—
Mafiufacturer Model 4
Licensed Plumber Certification
d.
ri 424 nail' I3/ 73
Print Name of Plumber license p Date
1 ce ' y 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_
U 6terinined 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 S Dwelling unit is connected directly to a meter installed by a water company _in accord c wit
M.G.L . c 186, §22(p), does not require the installation of a submeter. o fir%
Signed under the pains and penalties of perjury,
Signamy 4/7 tensed Plumber
Property Owner ertification
I 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 subrneter measu ring
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 subrneter 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, /
< / /9 A// C1_ CIn
i�iiiim � �i atr� U� - — n_ 0/4-1
' - tName • • 'ner atu ofO Date
_
/wwnner
�n?a z /o—/-7 o7
Board of Health/Hea th Department Received By Date
MDPHICSP Submetering Certification Form,Revised 10/06