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08/O1/2012 12:37 FAX 9529335049 CULLIGAN h[1VTRA I�003 <br /> f : :, .: �:'•ta==-��.,,,;.4. ti: <br /> i � i,...A� �'1 h 3:: ie.,a' G'�:�,�. :.,�;r!.0 <br /> x�o°I�;f,'."�Y�:..4�..�7k��:n�9•� (D,'•:.k p:'1�a:�i�r ��i':.!•Hp-.. <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 Washar <br /> Kitchen Sink Water Hester <br /> . , . .. Disposal _ , . _ , Water Softenor I _ <br /> Dishwasher Wct Bar <br /> Silicocks Misccllaneous <br /> � Yes,this section applies <br /> The replacement of a Rs�idenHel fixture or aR I�iance that meets all three of the following requirements: <br /> 1. Does not roquire modification to elecfical or gas service. <br /> 2. Hss a total cost of$500.00 or less;ex ' the cost of the fixture or appliance:and <br /> 3. [s improved,instailcd or replaced by the homeowner or licensed contractor. <br /> Skip next section,if this applies; Cost of Permit S l 5.00 <br /> State Surcharge S 5.00 <br /> Mail-I�Fee(If Applicable) S 2.00 <br /> Total Pe�nit Fee S <br /> (Permit Fees Contlnaed On Next Page) <br /> 2 <br />