112-114 Water & Sewer Certification Form 2011 MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH
SUBMETERING OF WATER AND SEWER CERTIFICATION FORM
:cordance with M.G.L.c. 186, §22 and 105 CMR 410.000:Minimum Standards of Fitness for Human Habitation
e Sanitary Code Chapter II).the following dwelling unit is eligible for the imposition on the tenants of a charge for
a and/or sewer service.
ress:
/Town:
PROPERTY INFORMATION
Uni
Of units inbld•. Z
QUIPMENT INSTALLATION INFORMATION
CMR 4o1 ten 0 ant requires a charge installation of
water
The'devic s prior to a
the following specifications: gtble for the
2 !h gallons per minute(2.5 gpm)
2 211°gallons per minute(2.2 gpm)
1 0'10 gallons per flush(1.6 gpf)
Zi. Code: 0
iwerheads with maximum flow rate not to exceed
icets with maximum flow rate not to exceed
ra low flush water closets(toilets)not to exceed
submetering equipment used to measure the quantity of water used for each dwelling unit and common area must
et the standards of accuracy and testing of the American Water Works Association or similar accredited association.
icensed plumber must install the water closets and
ometering equipment information:
0
Print Name of Plumber
epify that(check all that apply):
fl have installed the submetering equipment listed above in accordance with accepted plumbing standards.
11 have installed one or more water closets not exceeding 1.6 gallons per flush.
t5eterrnined that existing water closets do not exceed I.6 gallons per flush.
1 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 and,in accordance with•M.G.L.c. 186, §22(p),does not require the installation of a su
gned under the pains and penalties of perjury, nature of Licensed Plumber
Property Owner Certification
certify that:(1)This dwelling unit is eligible for the imposition on th tenants of a charge for w,and a /ooresewer usages ater
1 accordance with the water submetering law(MGL c. 186, §22);( )
welling unit are water conservation devices that meet the standards specified above;(3)The water submeter measuring
le use of water in the dwelling unit was installed by a licensed plumber and is in compliance with the standards
pecified above,or the water meter measuring the use of water in this dwelling unit was installed by a"water company°
s defined in M.G.L.c. 186, §22; (4)The water meter or submeter measures the water usage exclusive to this unit;(5)1
/ill provide to the tenants of this dwelling unit,prior to occupancy,a written rental agreement that
all tnfomytpro idesdor the
s for
eparate charging of water and/or sewer service,and a copy of this certification fore;( ) on
nis certification is true and accurate to the best of my knowledge.
iigned under the pains and penalties of perjury,
/4/1 ate"- � te#411 nIcr
Print Name of wner
Manufacturer
icensed Plumber Certification
License#
o
Model#
Date
•
Board f Health ealth D
•
4
in nt
MDPH/CSP Submetering Certification Form,Revised 10/06
ryitere of owner
seed By
Date
//— 7—//
Date
MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH
SUBMETERING OF WATER AND SEWER CERTIFICATION FORM
En accordance with M.G.L.c. 186, § 22 and 105 CMR 410.000:Minimum Sta�nd�a,r^d�s of F tness for Human Habitation
;State Sanitary Code Chapter II).the following dwelling unit is eligible for th7 i ;iti on the tenants of a charge for
// (� PROPERTY INFORMATION
Address: r`700,-141,244,400714h/{ 1 y/GS ST- Unit# A 15 #Of units in bld},. 2—
Uily/Town: MA Zip Code: 0/30i
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:
8howerheads with maximum flow rate not to exceed 2"gallons per minute(2.5 gpm)
Faucets with maximum flow rate not to exceed 2 L10 gallons per minute(2.2 gpm)
Ultra low flush water closets(toilets)not to exceed 1 X10 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
neet 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.
8ubmetering equipment information: Az Ir. Air do---
Manufacturer Model #
icensed Plumber Certification
"7-1---; t/ /1/ r rire20i/
Print Name of Plumber License A' Date
[cc$ify that(check all that apply):
I have installed the submetering equipment listed above in accordance with accepted plumbing standards.
j I have installed one or more water closets not exceeding 1.6 gallons per flush.
-'ISetermined that existing water closets do not exceed 1.6 gallons per flush.
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 and,in accordance with
M.G.L . c. 186. § 22(p),does not require the installation of a sub ter.
Signed under the pains and penalties of perjury,
ignature of Licensed Plumber
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
n accordance with the water submetering law(MGL c. 186, §22);(2)All showerheads, faucets,and water closets in this
Iwelling unit are water conservation devices that meet the standards specified above;(3)The water submeter measuring
he use of water in the dwelling unit was installed by a licensed plumber and is in compliance with the standards
:pecified above,or the water meter measuring the use of water in this dwelling unit was installed by a"water company"
is defined in M.G.L.c. 186, §22; (4)The water meter or submeter measures the water usage exclusive to this unit;(5)I
mill 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
his certification is true and accurate to the best of my knowledge.
iigned under the pains and penalties of perjury,
C Ir <� WLA--- 4- 7/I
/i/ilia m ¥ N -2
Print Name of wner - _m re of Owner Date
/ of
/linr-(%o,.n4 ✓%uv I-.ef"41- i _. I/' ?'//
Board df Health/Health De artm nt /tiver1 Rv Date
NDPH/CSP Submetering Certification Form,Revised 10/06