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.._ <br /> � � <br /> t <br /> . ..W� �3 �.��`"t ' fY '.� .„ ... ,.: .:`fi <br /> Y7.,� aK�y . _,�'Y $Y � . <br /> �S... _.a ��. �, , �,.�.��.,c.M .. ., � . ,-. .,. <br /> # <br /> . �..�k�."�. � P, �.s �, - : <br /> FIXTURE BSMT 1 2 OTHER FIXTURE BSMT 1 2 OTHER <br /> TYPE FL FL TYPE FL FL <br /> Water Closet t i Z Floor Drains , <br /> Lavatory ` 1 cZ Sewer Ejector <br /> J <br /> Bathtub 2 Laundry Tray ' <br /> Shower � Washer ' <br /> Kitchen Sink ` Water Heater t <br /> Disposal C Water Softener <br /> Dishwasher ' Wet Bar <br /> Sillcocks I Miscellaneous <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;excludins 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 />