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� <br /> � <br /> . <br /> ��. <br /> . <br /> ... , a'u,.�.�- .....' ... . ...� ...�w. ..���w,. , . . �.;. .. ..�os,e, .� � ,i . �. <br /> FIXTURE BSMT 1 2 OTHER FIXTURE BSMT 1 2 OTHER <br /> TYPE FL FL TYPE FL FL <br /> Water Closet / � Floor Drains <br /> Lavatory � Sewer Ejector <br /> Bathtub / Laundry Tray � <br /> Shower ,� W asher <br /> s� <br /> Kitchen Sink / Water Heater <br /> Disposal Water Softener <br /> Dishwasher Wet Bar <br /> Sillcocks Miscellaneous <br /> �'Y <br /> .. ,� ., .. <br /> ❑ Yes,this section applies <br /> The replacement of only one Residential fixture or appliance that meets all three of the following <br /> requirements: <br /> 1. Does not require modification to electrical or gas service. <br /> 2. Has a total cost of$500.00 or less;excludine the cost of the fixture or appliance: and <br /> 3. Is improved, installed or replaced by the homeowner or licensed plumbing contractor. <br /> Skip next section,if this applies; Cost of Permit $ 15.00 <br /> State Surcharge $ 5.00 <br /> Mail-In Fee(If Applicable) $ 2.00 <br /> Total Permit Fee $ <br /> (Permit Fees Continued On Next Page) <br /> 2 <br />