99 Water & Sewer Certification Form 2009 MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH
SUBMETERING OF WATER AND SEWER CERTIFICATION FORM
ecordance with M.G.L.c. 186. §22 and 105 CMR 410.000:Minimum Standards of Fitness for Human Habitation
te Sanitary Code Chapter II),the following dwelling unit is eligible for the imposition on the tenants ofa charge for
r and/or sewer service.
PROPERTY INFORMATION
CSP Submetering Certification Form,Revised 10/06
ress: 9�j7 S$€€ . / Unit it p Of units in bldg. Z
/Town: f /et/44 7e76h MA Zip Code:
QUIPMENT INSTALLATION INFORMATION
CMR 410.000 requires the installation of water conservation devices prior to a dwelling unit becoming eligible for the
tsition on tenants ofa charge for water and/or sewer.The devices must meet the following specifications:
verheads with maximum flow rate not to exceed 2 gallons per minute(2.5 gpm)
ets with maximum flow rate not to exceed 2 2 110 gallons per minute(2.2 gpm)
i low flush water closets(toilets)not to exceed I 6110 gallons per flush (1.6 gpf)
;ubmetering equipment used to measure the quantity of water 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.
ensed plumber must install the water closets and submetering equipment.
tetering equipment information: l r J '7�l,q
2,5
nufacturer Model#
Licensed Plumber Certification
%) lneif ;8)-jy�{
3/ 75-- ?-
Print Name of Plumber - License# Date
ify that(check all that apply):
awe installed the submetering equipment listed above in accordance with accepted plumbing standards.
lave 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.
to plumbing permit issued by the city/town, if required, is attached.
.welling unit is connected directly to a meter installed by a water comp. . d,in accor sa e with
.G.L . c. 186, §22(p), does not require the installation of a submete
Pia
I under the pains and penalties of perjury, ,J / - it' IP
r Signature of Licensed Plumber
Property Owner Certification
fy that: (I)This dwelling unit is eligible for the imposition on the tenants ofa charge for water and/or sewer usage
,rdance with the water submetering law(MGL c. 186, §22); (2)All showerheads, faucets,and water closets in this
ng unit are water conservation devices that meet the standards specified above;(3)The water submeter measuring
e of water in the dwelling unit was installed by a licensed plumber and is in compliance with the standards
led above,or the water meter measuring the use of water in this dwelling unit was installed by a"water company-
ned in M.G.L.c. 186,§22; (4)The water meter or submeter measures the water usage exclusive to this unit;(5)1
ovide to the tenants of this dwelling unit,prior to occupancy,a written rental agreement that clearly provides for the
te charging of water and/or sewer service,and a copy of this certification form, (6)That all information included on
rtification is true and accurate to the best of my knowledge.
I undef the pains and penalties of perjury, /
/1 ee v -_tel _ in (5 ✓/5Jfir`
'rint Name , I ner i. a re of Owner Date r
/
Board of Health/Health Department Received By nat.
CSP Submetering Certification Form,Revised 10/06