103 Certification Form 2009 MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH
SIJBNIETERING OF WATER AND SEWER CERTIFICATION FORM
n accordance with M.G.L.c. 186, §22 and 105 CMR 410.000: Minimum Standards of Fitness for Human I Iabitation
State Sanitary Code Chapter II),the following dwelling unit is eligible for the imposition on the tenants ofa charge for
mater and-or sewer service_
PROPERTY INFORMATION
4ddress: /03 fTa7' S-T Unit
k Of units in bldg.
'ity/Town: .I`'i f bt'i MA Gip Code: ( J,,,,
QUIPMENT INSTALLATION INFORMATION
05 CMR 410.000 requires the installation of water conservation devices prior to a dwelling unit becoming eligible for the
rnposition on tenants ofa charge for water and/or sewer.The devices must meet the following specifications:
Ihowerheads with maximum flow rate not to exceed
aucets with maximum flow rate not to exceed
lltra low flush water closets(toilets) not to exceed
2 gallons per minute(2.3 gpm)
2 2 i2i gallons per minute(2.2 gpm)
1 6'10 gallons per flush (1.6 gpf)
'he submetering equipment used to measure the quantity of water used for each dwelling unit and common area must
tees the standards of accuracy and resting of the American Water Works Association or similar accredited association
licensed plumber must install the water closets and submetering equipment
ubmetering equipment information: _ SCACltir / 6 e- z 5-
Man acturer Model #
Licensed Plumber Certification
7(nen— --
) /3l 76
Print Name of Plumber License# Date
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.
ttermined that existing water closets do not exceed 1.6 gallons per flush.
7 The plumbing permit issued by the city/town, if required, is attached.
Dwelling unit is connected directly to a meter installed by a water company d, in ac rdance with
M.G.L. c. 186, §22(p),does not require the installation of a submeter.
gned under the pains and penalties of perjury, e"
Signature of Licensed Plumber
Property Owner Certification
ertify that:(1)This dwelling unit is eligible for the imposition on the tenants ofa charge for water and/or sewer usage
accordance with the water submetering law(MGL c. 186, §22);(2)All showerheads, faucets,and water closets in this
felling unit are water conservation devices that meet the standards specified above;(3)The water suhmeter mean ui no
:use of water in the dwelling unit was installed by a licensed plumber and is in compliance with the standards
:Tilled above_or the water meter measuring the use of water in this dwelling unit was installed by a"water company"
defined in M.G.L.c. 186, §22; (4)The water meter or submeter measures the water usage exclusive to this unit;(5)1
II provide to the tenants of this dwelling unit,prior to occupancy,a written rental agreement that clearly provides for the
)arate charging of water and/or sewer service,and a copy of this certification form; (6)That all information included on
s certification is true and accurate to the best of my knowledge.
coed under the pains and penalties of perjury,
/Az iH L 6 / u 4a .o�y
7.---Print Name(yOwner Si mat t a'I er Date
_
O
a /v"PC/� 761-/is"O 5
Board of Health/Health Department Received By Date
)PH/CSP Submetering Certification Form,Revised 10 106
MASSACHUSETTS DEPARTMENT OF PUBLIC HEAL CH
SUBMETERJNG OF WATER AND SEWER CER FIFICATION FORM
accordance with M.G.L. c. 186, v'22 and i05 CMR 410.000: Minimum Standards of Fitness for Human Habitation
ate Sanitary Code Chapter II),the following dwelling unit is eligible for the imposition on the tenants ofa charge for
ter and/or sewer service.
PROPERTY INFORMATION
dress; 7&3 5417?- st Unit,# 3 a Of units in bldg.//
efown: �61e- d�uiif/J (�I� MA Zip Code: /(��pl✓j
EQUIPMENT INSTALLATION INFORMATION
i CMR 410.000 requires the installation of water conservation devices prior to a dwelling unit becoming eligible for the
position on tenants ofa charge for water and/or sewer_The devices must meet the following specifications:
awerheads with maximum flow rate not to exceed
icets with maximum flow rate not to exceed
ra low flush water closets(toilets) not to exceed
2"gallons per minute(2.5 gpm)
2 eft gallons per minute(2.2 gpm)
1 ° 1a gallons per flush(1.6 gpf)
e submetering equipment used to measure the quantity of water used for each dwelling unit and common area must
el the standards of accuracy and testing of the American Water Works Association Or similar accredited association_
icensed plumber must install the water closets and submetering equipment.
'metering equipment information:
//?2!
Print Name of Plumber
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.
ermined that existing water closets do not exceed 1.6 gallons per flush.
The plumbing permit issued by the city/town,if required, is attached.
4Ct
M9hufacturer
Licensed Plumber Certification
./1125'
Model #
/3 / 7t5
License 4
5751/7g5 a,
Dwelling unit is connected directly to a meter installed by a water compap nd,in acs r.. y. with
M.G.L. c. 186. § 22(p), does not require the installation ofa submet
ned under the pains and penalties of perjury,
Si•n.ure of Licensed Plumber
Property Owner Certification
ertify that (I)This dwelling unit is eligible for the imposition on the tenants ofa charge for water and/or sewer usage
accordance with the water submctering law(MGL e- 186, §22);(2)All showerheads,faucets,and water closets in this
ailing unit are water conservation devices that meet the standards specified above;(3)The water submeter measuring
use of water in the dwelling unit was installed by a licensed plumber and is in compliance with the standards
cified above, or the water meter measuring the use of water in this dwelling unit was installed by a 'water company"
Iefined in M.G.L. c. 186, §22; (4)The water meter or submeter measures the water usage exclusive to this unit; (5) 1
I provide to the tenants of this dwelling unit,prior to occupancy,a written rental agreement that clearly provides for the
arate charging of water and/or sewer service.and a copy of this certification form; (6)That all information included on
certification is true and accurate to the best of my knowledge.
ned under the pains and penalties ofperjury,
/
Pr nt Name o • ner
///. //
Board of I Rahn/Health Department Received By
nn
6 4lO-(-/`$
Date
/4—/2 d
Date
PH/CSP Submeterino Certification Form, Revised 10/06
MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH
SUBMETERING OF WATER AND SEWER CERTIFICATION FORM
sordance with M.G.L_c. 186. § 22 and 105 CMR 410.000:Minimum Standards of Fitness for Human Habitation
s Sanitary Code Chapter I I),the following dwelling unit is eligible for the imposition on the tenants of a charge for
PROPERTY INFORMATION
V
Unit pc Of units in bldg.
ess: /0;
�( /J15 )
Town: �pjy 4 nf.Kf eyi MA Zip Code:
EQUIPMENT INSTALLATION INFORMATION
:MR 410.000 requires the installation ofwater conservation devices prior to a dwelling unit becoming eligible for the
si tion on tenants of a charge for water and/or sewer. The devices must meet the following specifications:
verheads with maximum flow rate not to exceed 2'2 gallons per minute(2.5 gpm)
ets with maximum flow rate not to exceed 2 3110 gallons per minute(22 gpm)
i low flush water closets(toilets)not to exceed 10"0 gallons per flush (1.6 gpf)
submetering equipment used to measure the quantity ofwater used for each dwelling unit and common area must
the standards of accuracy and testing of the American Water Works Association or similar accredited association_
sensed plumber must install the water closets and submetering equipment.&
information: »1
netering equipment JBr,
Man(facturer Model 4
4/ Licensed Plumber Certification
i 141-7 Print Name of Plumber - License 4 Date
Lily that(check all that apply):
have installed the submetering equipment listed above in accordance with accepted plumbing standards_
have installed one or more water closets not exceeding 1.6 gallons per flush.
determined that existing water closets do not exceed 1.6 gallons per flush_
:he plumbing permit issued by the city/town, if required, is attached.
dwelling unit is connected directly to a meter installed by a water company and,in ac-tr.ante with
VI_G.L. c. 186, §22(p),does not require the installation of a submeter.
WA
of
led under the pains and penalties perjury,
Sisi'amre of Licensed Plumber
Property Owner Certification
tify that: (I)This dwelling unit is eligible for the imposition on the tenants of a charge for water and/or sewer usage
:cordance with the water submetering law(MGL,c. 186,§22);(2)All showerheads, faucets,and water closets in this
fling unit are water conservation devices that meet the standards specified above;(3)The water submeter measuring
Be of water in the dwelling unit was installed by a licensed plumber and is in compliance with the standards
;Hied above,or the water meter measuring the use of water in this dwelling unit was installed by a"water company"
efined in M.G.L. c. 186, §22; (4)The water meter or submeter measures the water usage exclusive to this unit;(5)1
provide to the tenants of this dwelling unit,prior to occupancy,a written rental agreement that clearly provides for the
Irate charging of water and/or sewer service,and a copy of this certification form;(6)That all information included on
certification is true and accurate to the best of my knowledge.
Led under the pains and penalties of perjury, i
n
6/1/7l 7/2 vl2lL rr,"' L---
3 int Name o iwner w�+ ure of Owner Date
,,eg,X—rift - /U /J o 7
�. . /4,:n...it
_. r.,...,......e... Received By Date
oar d of Health:
PHICSP Submeterng Certification Form,Revised 10'06
MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH
SUBMETERINO OF WATER AND SEWER CERTIFICATION FORM
:cordance with M.G.C.. c. 186, §22 and i 05 CMR 410002 Minimum Standards of Fitness for Human Habitation
e Sanitary Code Chapter II).the following dwelling unit is eligible for the imposition on the tenants ofa charge for
PROPERTY INFORMATION
ross: /03 5//- Q Unit e /
°Of units in bldg.
Zip Code: r9/0(4:7 C)
unit becoming eligible for the
specifications:
gpm)
gpm)
and common area must
accredited association_
//,�+3
Town: /Or 4 (� n MA
EQ IPMENT INSTALLATION INFORMATION
CMR 410.000 requires the installation ofwater conservation devices prior to a dwelling
tsition on tenants ofa charge for water and/or sewer. The devices must meet the following
rrerheads with maximum flow rate not to exceed 2 `gallons per minute(2.5
tets with maximum flow rate not to exceed 22F0 gallons per minute(2.2
I low flush water closets (toilets)not to exceed I Gt°gallons per flush (1.6 gpf)
submetering equipment used to measure the quantity of water used for each dwelling unit
t the standards of accuracy and testing of the American Water Works Association or similar
sensed plumber must install the water closets and submetering equipment.
netering equipment information: 20-01CC/( -/–
/1/;, -,5
Model 4
'Manufacturer
Licensed Plumber Certification
4 /3/ 7,5`
�$
Date
standards_
ce with
f tr e!? -- -
Print Name of Plumber - License=
lily that(check all that apply):
have installed the submetering equipment listed above in accordance with accepted plumbing
have installed one or more water closets not exceeding 1.6 gallons per flush.
)etermined that existing water closets do not exceed 1.6 gallons per flush.
fhe plumbing permit issued by the city/town, if required,is attached.
)welling unit is connected directly to a meter installed by a water company .nd, in accord.
N_G.L.c. 186, § 22(p), does not require the installation ofa submeter. .,
ied under the pains and penalties of perjury, S I
Si•natu of Licensed Plumber
Property Owner Certification
tify that: (1)This dwelling unit is eligible for the imposition on the tenants ofa charge for water and/or sewer usage
:cordance with the water submetering law(MGI.c. 186, §22); (2)All showerheads, faucets,and water closets in this
Iling unit are water conservation devices that meet the standards specified above;(3)The water submeter measuring
tse ofwater in the dwelling unit was installed by a licensed plumber and is in compliance with the standards
-ified above,or the water meter measuring the use of water in this dwelling unit was installed by a"water company'
efined in M.G.L_c 186, §22: (4)The water meter or submeter measures the water usage exclusive to this unit;(5) I
provide to the tenants of this dwelling unit,prior to occupancy,a written rental agreement that clearly provides for the
irate charging of water anchor sewer service,and a copy of this certification form; (6)That all information included on
certification is true and accurate to the best of my knowledge.
red under the pains and penalties of perjury,
/ . P /i /
� ne,
/WU/Aar' £eft ' L/- n _el
Print Nameoowne -re of Owner
//
Date
l�/.SOS
/T /� /S
/ ^ �7in eE �" �/
R...r Mralth ()enactment Received By Date
PH•CSP Submetering Certification Form,Revised 10:06