HomeMy WebLinkAbout0150 HINCKLEY ROAD - Health 150 Hinckley Road
Hyannis
A= 311-064
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:/5-0 1111a,1101 /4. Unit# #Of units in bldg. =L.
l
Ci /Town: �-z-a"a`" 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 2'1 gallons per minute(2.5 gpm)
Faucets with maximum flow rate not to exceed 2 J10 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 American Water Works Association or similar accredited association.
A licensed plumber must install the water closets and submetering equipment. L/�f r
Submetering equipment information:
Manuf cturer
Licensed Plumber Certification
Iv T-;F2 `l- Z-0 J 14--o AOL -75-4
Print Name of Plumber License# Date
I certify that(check all that apply):
❑1 have 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. _ � s-;1 s
[&Determined that existing water closets do not exceed 1.6 gallons per flush. 7
❑ 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,
i ture 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, /
17-1
Print Naft 4 Owner Ariinature of Owner ` ate
�w,
r
Board of It eA De artment Received B ate
MDPH/CSP Submetering Certification Form,Revised 10/06
1