49 Water & Sewer Certification Form 2009 MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH
SUBMETERING OF WATER AM) 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 ofa charge for
water anchor sewer service.
/ PROPERTY INFORMATION
Address: y9 (lA/ / r Unit 4 #Of units in bldg. 2
CitvTown: die,N fi ,, MA Zip Code: C/C60
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 ofa 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 2210 gallons per minute(22 gpm)
Ultra low flush water closets(toilets) not to exceed 1 °''0 gallons per flush (L6 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 W orks Association or similar accredited association-
A licensed plumber must install the water closets and submetering equipment.
Submetering equipment information: 8e cr _ /11?3
Ma facturer Model #
Licensed Plumber Certification
-Tip, 74;7 alt 133 7,S
Print Name of Plumber License R Date
I ce v that(check all that apply):
I have installed the submetering equipment listed above in accordance with accepted plumbing standards.
❑ IIhhave installed one or more water closets not exceeding 1.6 gallons per flush.
U titermined that existing water closets do not exceed 1.6 gallons per flush.
I I The plumbing permit issued by the city/town, if required, is attached.
fFp Dwelling unit is connected directly to a meter installed by a water company and, in .ecordance with
M.G.L . c. 186, § 22(p), does not require the installation ofa subme i
Signed under the pains and penalties of perjury, _J/') 14 el V
'ignature of Licensed Plumber
Property Owner Certification
I certify. that:(I)This dwelling unit is eligible for the imposition on the tenants 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`Seater 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,
! i > / i / �/ . tzli r_n
'1 - , v , �.r,- tS ��'
_frier
print Narpvo •vn• nature of Owner Date r
V`°' � � „4„,, ,i_77,„F -- /62-72'o9
Board of Health/Heaith Department Received By Date
MDPH/CSP Submetering Certification Form, Revised 10/06