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Home My WebLink AboutMiscellaneous - 123 MASSACHUSETTS AVENUE 4/30/2018 (2) 123 MASSACHUSETTS AVENUE - - - - ---- - - -_- - - -- - 2101006._0-0021-0000.0 �- •' �\ `. ( i 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, PROPERTY INFORMATION Address: M.5 NJ rIK QJ-eA-WVe a Unit# #Of units in bldg. City/Town: Coe A (j/oile-- MA Zip Code: ®0 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 i gallons per minute(2.5 gpm) Faucets with maximum flow rate not to exceed 2 2/10 gallons per minute(2.2 gpm) Ultra low flush water closets(toilets)not to exceed 1 6110 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: �c�J, p� Manufacturer Model # Licensed Plumber Certification 7%W c0tlz�-t Print Name of Plumber License# Date I cei ' that(check all that apply): have 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. R 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. 186, §22(p),does not require the installation of a submeter. Signed under the pains and penalties of perjury, Signature of Licensed Plumber Property Owner Certification I certify that:(1)This dwelling unit is eligible for the imposition 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 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)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, p Z—A0 AVk-,V,-1 A0 Print Name of/Owner Signature of Owner Date ` D✓'jt, sf7VLv /brZ� — J0. Board of Health/Health Department R eiv d By Date MDPH/CSP Submetering Certification Form,Revised 10/06 -F I -c--- C-b 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, PROPERTY INFORMATION Address: �%.�' �ffPRG cc�e7l�S��Glite, Unit# #Of units in bldg. City/Town: 00 doves MA Zip Code: 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!/2 gallons per minute(2.5 gpm) Faucets with maximum flow.rate not to exceed 2 2"0 gallons per minute(2.2 gpm) Ultra low flush water closets(toilets)not to exceed, 1 "0 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 accurac} 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: -A41e, Q� Manufacturer Model # Licensed Plumber Certification Print Name of Plumber License# Date I cei ' that(check all that apply): have installed the submetering equipment listed above in accordance with accepted plumbing standards. leave installed 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. 186, §22(p),does not require the installation of a submeter. Signed under the pains and penalties of perjury, Signature of Licensed Plumber Property Owner Certification I certify that: (1)This dwelling unit is eligible for the imposition 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 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, /0 -07 X-/r 0�?rlttr-j Ifl'ielaikcci — — Print Name of Owner Signature of Owner Date o r�"L. �v►�b V e�- �b � Z� - r te Board of Health/Health Department R eiv d 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, PROPERTY INFORMATION rddress: oZ �ItZ�jS.11G�kfeS �v� �r� Unit# #Of units in bldg. a City/Town: A40 417 a/0 MA Zip Code: 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 rnaximum flow rate not to exceed 2 '/'gallons per minute(2.5 gpm) Faucets with maximum flow rate not to exceed 2 2/10 gallons per minute(2.2 gpm) 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 AmericanWater Works Association or similar accredited association. A licensed plumber must install the water closets and submetering equipment. Submetering equipment information: 4A 4C�.� d S Manufacturer Model # Licensed Plumber Certification ` 1 C 'pope 1341 Print Name of Plumber License# Date I certify that(check all that apply): �I have installed the submetering equipment listed above in accordance with accepted plumbing standards. 13,! ve installed 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. 186, §22(p),does not require the installation of a submeter. Signed under the pains and penalties of perjury, Signature of Licensed Plumber Property Owner Certification I certify that: (1)This dwelling unit is eligible for the imposition on the tenants of 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, Ile Print Name of Owner Si-nature of Owner Date Board of Health/Health Department Received Date MDPH/CSP Submetering Certification Form,Revised 10/06 Date. /D /Z • MORTN • OF'..ao 3? TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION ..�o•rr,qh SACHUSEt tl This certifies that . .��"��./. . . . . . . . . . .��. . . . has permission for gas,installation in the buildings of .//. �.-�..� . . ..1 . . . at , North Andover, Mass. Fee.-W), Lic. No.. . . . 3 . . . AS INSPECTOR Check# 11 Y 4558 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or T • , Mass. Date Dcc, zac • P mnit # Building Location 1 L123 Afi" J4et f-e Owner's'Nam A(Js, ZL4262 Gam. Type of Occupanry New ❑ Renovation ❑ Replacement It Plans Submitted: Yes❑ No ❑ IC y ► - y W y - Y Z cc U; y y V y0 co j W rt O 0 m f S 71 y z a u r < x _ o r W < Cr o o z r m W < y W H y d C > 4 UA W W y W 2 V W44 y W < U r W r S J W d o > W }W. U J h ¢ Y < W J < C ~ r y. y m 2 O 2 � 0 _._ < r < ,W > x W � Z. S < < . O O W O 11t SUB—SSMT. BASEMENT 1ST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR 5TH FLOOR 6TH FLOOR 7TH FLOOR STH FLOOR Installing Company Name CjAe Le T A . �5AIn MA T w-)i 0 Check one: Certificate Address 3 C'(�A t H�n F1 ry Lt�i. ❑ Corporation Al E T H UE � J1 ►a 0 ❑ Partnership Business Telephone /o�f2 -17 9"7 1 2--Firm/Co. Name of Licensed Plumber or Gas Fitter -( ()jBEPT A �AMrYI>q r� 4 INSURANCE COVERAGE: I have a current liability insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142.. Yes No ❑ If you have checked Les, please indicate the type coverage by checking the appropriate box A liability insurance policy 011" , Other type of indemnity❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner❑ Agent ❑ 1 hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the pei ed for this application ' be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 ofner Laws. BY T of License: G� Title *L.U,,.Ier ber n ure of Licensedu or Gas itter License Number3City/Town eyman APPPavE6T0—FF1—crUn-5—NL-'?V— I r I BELOW FOR OFFICE USE ONLY f FINAL INSPECTION SKETCHES PROGRESS INSPECTION FEE NO. APPLICATION FOR PERMIT TO DO GASFITTING I � NAME A TYPE OF BUILDING LOCATION OF BUILDING PLUMBER OR GASFITTER LIC. NO. _ 1 PERMIT GRANTED DATE__r19 fI GASINSPECTOR