Loading...
66 Unit 1-4 Submetering of Water & Sewer 2009 MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH 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 PROPERTY INFORMATION Address: 6,t/ E i utt/T�'40 4 -Unit# / #Of units in bldg. V ��/�e5t City/Town: // --airi/>i MA Zip Code: 290'6 o 105 imposition Showerheads 1 Faucets Ultra The meet A licensed Submetering EQUIPMENT INSTALLATION INFORMATION CMR 410.000 requires the installation of water conservation devices prior to a dwelling unit becoming eligible for the on tenants of a charge for water and/or sewer. The devices must meet the following specifications: with maximum flow rate not to exceed 2"gallons per minute(2.5 gpm) with maximum flow rate not to exceed 2 2°0 gallons per minute(2.2 gpm) low flush water closets (toilets)not to exceed I x10 gallons per flush(1.6 gpf) submetering 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. plumber must install the water closets and submetering equipment. equipment information: yf L J257 ono,),--. co �I--i �S Manufacturer Model # I ceII Licensed Plumber Certification • .y 1198D 7Iag(o9 Print Name of Plumber License d Date that(check all that apply): ave 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. that existing water closets do not exceed 1.6 gallons per flush. plumbing permit issued by the city/town, if required, is attached. unit is connected directly to a meter installed by a - .' pany and,in accordance with M.G.L . c. 186, §22(p).does not require the installation e a subm- -r. under the pains and penalties of perjury, �/// - i • 1 ©15etermined • The • Dwelling Signed _ T nature of Licensed Plumber Property e ner Certification I certify that: (1)This dwelling unit is eligible for th= mposition 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 1 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) 1 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, / / • 1 11 / f, /�/% !N! ((I d+7R V.€ 10 0 Cv— , /_CL—C,i Print Name o Owner d ••-le...0 Owner Date viol ����. �/ t6 —a7 Boar , iIth/MP" rlenartment Receive. By Date o• MDPHICSP Submetering Certification Form,Revised 10/06 MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH 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 11),the following dwelling unit is eligible for the imposition on the tenants of a charge for water and/or sewer service. i PROPERTY INFORMATION // Address: //''��/a* �Q(p ///t /s Unit= % #Of units in bldg. ]` Citv/Town: if`^8+ 7nr'/ MA Zip Code: cY/O6, 0 iy 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 ofa charge for water and/or sewer.The devices must meet the following specifications: I Showerheads with maximum flow rate not to exceed 2`gallons per minute(2.5 gpm) I Faucets with maximum flow rate not to exceed 2'10 gallons per minute(2.2 gpm) I Ultra low flush water closets (toilets)not to exceed 1 6 10 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. an -kin rr ai'm TiL3 75 Submetering equipment information: ] �d. L. Manufacturer Model# Licensed Plumber Certification Tames N ujJ-&f 11-730 7/x8109 i Print Name of Plumber License 4 Date I certify that(check all that apply): HIT-aye 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. Et15;termined that existing water closets do not exceed 1.6 gallons per flush. • The plumping permit issued by the city/town, if required, is attached. • Dwelling unit is connected directly to a meter installed by water c. pany an . ' ccord.. e with M.G.L.c. 186, §22(p).does not require the installatio fa sub •-ter. Signed under the pains and penalties of perjury, i .IL/> yy.07/ a/Armature of Licensed Plumber Property 5 caner Certificatio I certify that:(1)This dwelling unit is eligible forth; mposition on the te,•nts ofa 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)1 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, e-� b (train lien IZ€F— /l,44v �iri,.WC.i /-LZ_ ' / Print NN me of Owner re of Owner Date �. �L / /% Try e--6 'b% .??iti€ _/r Board of Health/Ha61th Department Received By Date MDPH/CSP Submetering Certification Form,Revised 10/06 MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH 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. ! Address: 4/1 �r PROPERTY INFORMATION Unit g #Of units in bldg. City/Town: A/041-45-cfrets iA4A Zip Code: 0/C76(7 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`gallons per minute(2.5 gpm) Faucets with maximum flow rate not to exceed 2 an0 gallons per minute(2.2 gpm) Ultra low flush water closets(toilets)not to exceed 1 °a0 gallons per flush(1.6 gpf) The submetering equipment used to measure the quantity ofwater 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: -Dann Y L. T-4AYhan Co - kL 76 Manufacturer Model# Licensed Plumber Certification James t i k,+ n 11`)80 7 @ 3- i 9 Print Name of Plumber License# Date 1�cye/rt�ify that(check all that apply): L_n nave 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. etermined 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 watere any and,in accordant with M.G.L . a 186, § 22(p), does not require the installation ooya submet Signed under the pains and penalties of perjury, eal(� re of Licensed Property Ow er Certification I certify that (1)This dwelling unit is eligible for the imposition on the tenant 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 plumper and is in compliance with the standards specified above,or the water meter measuring the use ofwater 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, r, it r / / L.. /1/Y --o W2 /tin t efr2k�eC (.vim n.7, / "L 1-4=` Print Nanfe of Owner -i-ture of Owner Date i/ /i/ YL ffOS - . .�/e��i �` Board of Health/Healt 1epartment r Received By Date MDPH/CSP Submetering Certification Form.Revised 10/06 MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH 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 11),the following dwelling unit is eligible for the imposition on the tenants of a charge for water and/or sewer service. /' y� PROPERTY INFORMATION /� 7 Address: £ , /Xi&J I S ( Unit# 49 #Of units in bldg. V // City/Town: /VerVieps 3n MA Zip Code: 19/06 0 EQUIPMENT INSTALLATION INFORMATION 1 105 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 "gallons per minute(2.5 gpm) Faucets with maximum flow rate not to exceed 2- gallons per minute(2.2 gpm) Ultra low flush water closets (toilets)not to exceed 1 610 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: ] nil L. jevr gin CO. ' f_1 -15 Manufacturer Model# Licensed Plumber Certification Ca 1'YI e,S Iv Qa01-071 117 CD 7I I?i CO Print Name of Plumber License# Date I certify that(check all that apply): ®lave installed the submetering equipment listed above in accordance with accepted plumbing standards. 1445,,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. IN The plumbing permit issued by the city/town,if required, is attached. II Dwelling unit is connected directly to a meter installed by a company and,in accore ii ee with M.G.L. c. 186, § 22(p), does not require the installatio ter. / Signed under the pains and penalties of perjury, //, - -E 17rs allirrature of Licensed Plumber Property 1 nor Certification I certify that:(1)This dwelling unit is eligible for the' position on the tenan ofa 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)1 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, 4 ;; 1 /� A i ,gay -r _ Z2-te n - >�reo Timer Dare ,,//��PrintNa��jofOwner Ieilir1 I/O f , i. -,,: Ar O f reii Board of Health/Health Department Received By Date MDPH/CSP Submeterine Certification Fenn.Revised 10/06