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SUBMETERING OF WATER AND,$EWER CERTIFICATION FORM
In accordance with M.G.L.c, 186, § 22 and 105 CMR 410.000:Minix uni Standards of Fitness•for Human Ilabiiatlon, Stare
Sanitary Code, Chapter!1 the"Housin Code" ,the following dwelling unit is eligible for submetering water and sewer,
PROPERTY INFORMATION j
Address: /O A17 Xa d LS Unit# 0 'kk #Of units in bldg.
City/Town: NO. MA Zip Code: 0/,?41,5-
EQUIPMENT INSTALLATION INFORMATION
105 CMR 410.130(C)requires the installation of water conservations devices prior to a dwelling unit.becoming eligible for
submeterhig for water and/or sewer services.The devices must meet the following specifications:
Showerheads with maximum flow'rate not to exceed 2,5 gallons per minute(gpm)
Faucets with maximum flow rate not to exceed 2.2 gallons per minute(gpm)
Ultra-low flush toilets not to exceed 1,6 gallons per flush(gpo..
The submetering equipment used to treasure 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 Massachusetts licensed plumber must install the toilets and submetering equipment.
Submetering equipment information: S A D G(=
Manufacturer Model#
LICENSED PLUMBER CERTIFICATION
I certify that(check all that apply):
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❑ I have installed or inspected the submetering equipment listed above and have determined that they meet accepted plumbing standards.
I have installed or inspected all the toilets in this unit and have determined that they meet accepted plumbing standards.
❑� The plumbing pennit issued by the city/town,if required,is attached.
❑This dwelling unit is connected directly to a meter installed by a water company and,in accordance with KO.L.c. 186,§22(p),does
not require the installation of a submeter.
Licensed Plumber's Name Plumber' Signature License# Date
OWNER CERTIFICATION
I certify that;
(l)This dwelling unit is eligible for submetering of water and/or sewer usage in accordance with the water submetering law
(MGL c. 186, §22).
(2)All showerheads,faucets and toilets in this dwelling unit meet the conservation standards spccitied above.
(3)The water submeter(if present)measuring the use of water in this dwelling unit was installed by a licensed plumber and
complies with the standards of accuracy and testing required by the water submetering law(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) All information included on this certification is true and accurate to the best of my knowledge.
THIS FORM MUST BE FILED WITH THE LOCAL HEALTH DEPARTMENT PRIOR TO INITIATING SUBMETERING
Signed under the pains and penalties of perjury, -yam
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Name of Owner Signature of Owner Date
The property bas been transferred to the owner above and tho unit remains in compliancy:with ilia requirements of M.G.I.c. Date Submitted to Local Heal I'{
lab§2z- Departnreii t 6 1J f l
Friar Ownrr's Slgnaiure Date
,
410-23-Submetering of Water and Sewer Certification Form 5-12-23