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09/29/2011 10:47 FA% 9529335049 CULLIGAN MNTRA I�003 <br /> -^' �.i�' . " ��i'�[�B.�T�;,�� '$ETNC��TST�9,�;fD�, � <br /> FIXTURE BSMT l Z OTHER FIXTURE BSMT 1 2 OTHER <br /> TYPE FL FL TYPE FL FL <br /> Water Closet Floor Drains • <br /> Lavatory Sewer Ej�tor <br /> Bathtub Laundry Trey <br /> Shower Washer <br /> Kitchen Sink Water Heater <br /> Disposal Water Softener <br /> Dishwasher Wet Baz <br /> Sil lcocks Miscelleneous <br /> �h: 7.• . r . ,:��, . � <br /> '��' :i." i . �h'�; {�` '� . '•'- ";,��. .,,• ..r ,i <br /> � a' -'La�. 1 ..ii' ' ,• ',��",7,.,:�;:.��;"'u•L �i •:�. •i <br /> � Yes,this section applies <br /> �� <br /> � The replacement of a Residential fixture or a I�g iance that meets all three of the following requirement�; <br /> 1. Does not requue modification to electrical or gas secvice. <br /> 2. Has a to ost of$500.00 or less;excludin¢the cost of the fixture or appliance:and <br /> 3. Is improved,installed or replaced by the homeowner or iicensed 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 S <br /> (Permit F'ees Continued On Next Page) <br /> 2 <br />