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08/19/2013 14:18 FAX 9529335049 CULLIGAN MNTBA 1�003
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<br /> FD(TURE BSMT 1 2 OTHER FiXTURE BSMT 1 2 OTHER
<br /> Typg FI. FL TYPE FL FL
<br /> Water Closet Floor Drains
<br /> Lavatory Sewer Ejector
<br /> Bathtub Laundry Tray
<br /> Shower Washer
<br /> Kitchen Sink Water Heater
<br /> Disposal Water Softener �
<br /> Dishwasher W�B�
<br /> 5������ Miscellaneous
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<br /> ❑ Yes,this section applies
<br /> The replacement of a Residential fixture or apaliance that meets all three of the following requirements:
<br /> l. Does not require modification to electrical or gas service.
<br /> 2. Has a total co of$500.00 or less;excludin�the cost of the fixture or appliance:and
<br /> 3. Is improved,instalted or replaced by the homeowner or licensed contractor.
<br /> Skip next section,if this applies; Cost of Permit $_ 15.Q0
<br /> State Surcharge $ 5.60
<br /> Mail-In Fee(If Applicable) $ 2.00
<br /> Total Permit Fee �
<br /> (Permit Fees Contioued On Next Page)
<br /> 2
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