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r <br /> r <br /> � <br /> 1_ � <br /> � �s q . v � *.��: ^_�� . <br /> �"; ''�� s�� �' �r. h�^g r - �` °^' <br /> FIXTURE BSMT 1 2 OTHER FIXTURE BSMT 1 2 OTHER <br /> TYPE FL FL TYPE FL FL <br /> Water Closet j � 11 Floor Drains � <br /> � o� <br /> Lavatory t � Sewer Ejector <br /> I <br /> Bathtub � Laundry Tray <br /> Shower ' Washer � <br /> Kitchen Sink I Water Heater � <br /> Disposal I Water Softener <br /> Dishwasher � Wet Bar <br /> Sillcocks J Miscellaneous <br /> 1 <br /> ., . � . � <br /> , � <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 $ 1.00 <br /> Mail-In Fee(If Applicable) $ 2.00 <br /> Total Permit Fee $ <br /> (Permit Fees Continued On Next Page) <br /> 2 <br />