HomeMy WebLinkAboutApplication - 14 PURITAN AVENUE 12/18/2012 ,211812012 10:26 FAX 781 937 1702 ANALOG DEVICES
- f ►001/401
MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH
SUBMETERING OF WATER AND SEWER CERTIFICATION FORM
In accordance with XG.L.c, 186,§22 and 145 CMP 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-,enaftts of a charge for
water and/or sewer service,
7s: 1p OPE�.TYt INFORMATION
Ad �K," V�
Unit# #Of units in b1
Ci /Town: Q� h Ah q*- MA zi Code: o
EQUIPMENT INSTALLATION OR ATION
105 CMR 41 0.000 requites 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 spec;if cations.
Showerheads with maximum flow rate not to exceed 2%fallons 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 `11°gallons per flush(1.6 gpf)
The submetering equipment used to measure the quantity of water used for each dwelling unit unit oomrnon area must
meet the standards of accuracy and testing of the American Water Works Association or similar«.cc;redited association.
A licensed plumber must install the water closets and submetering equipment.
Submetering equipment information;
Manufacturer Model#
Licensed Plumber Certification
Print Name of Plumber l.iccnse# Date
i certify that(check all that apply):
1 have installed the submetering equipment listed above in accordance with accepted plumbing standards.
have instal led 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.
❑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. 196, §22(p),does not require the installation of submeter.
Signed under the pains and penalties of perjury,
Si _tune of)Licctnsed Plumber
Property Owner Certification
1 certify that:(1)This dwelling unit is eligible for the imposition on the tenants of a charge for wetter and/or sewer usage
in accordance with the water submetering law(MCai.,c. 186, §22);(2)All showerheads,faucets, od water closets in this
dwelling unit art 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 wkh 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.I..c. 186, §22; (4)The water meter or submeter measures the water usap ex-.dasive to this unit;( )1
will provide to the tenants of this dwelling unit,prior to occupancy,a written rental agreement timt 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,
gov Wo ! iA phi
Print Name of Owner i of 4 er } Date
card of Heal / e ith a ®rtrn,en R ed 13 e
MDPH/CSP Submetering Certification Dorm,Reviscd 10/06
MARK BURKE
PLUMBING TING
272 Kenoza Street
HAVERHILL, MA 01530
(978) -7 PHONE DATE OF ORDER ''..
TO ORDER TAKEN By _ CUSTOMER'f,OPOERNUMBER
C] DAY WORK ❑ CONTRACT j EXTRA
JOB NAME -UMBER _— —
JOp LOCATION
JOB PHONE STARTING DATC
TERMS:
7 Y'. .. fUW :AIV(t tJN'T, t� rl�TC�
UnColleated debts are Subject to Interest and all
Yo-
collect this dabt
TOTAL OTHER
LCMp WqS l �lE AMCIUtdll
TOTAL LABOR
DA'7E COMPLETED
TOTAL MATERIALS TOTAL MATERIALS
TOTAL OTHER j
Work ordered by
TAX
Signature --------
I hereby acknowfodge Iho satisfactory completiolf of the above described woik. —y — v TOTAL_
1
I
I