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t <br /> . ��;,�; . ��������� . ��'�"�� <br /> FIXTURE BSMT 1 2 OTHER FIXTURE BSMT 1 2 OTI�R <br /> TYPE FL FL TYPE FL FL <br /> Water Closet r� Floor Drains <br /> O� <br /> Lavatory � Sewer Ejector <br /> Bathtub ' Laundry Tray <br /> Shower � Washer <br /> Kitchen Sink Water Heater <br /> Disposal Water Softener <br /> Dishwasher Wet Baz <br /> Sillcocks n Miscellaneous <br /> G� <br /> , � ;; ���'��'�� �;�"����: � <br /> � � _ „. �� , <br /> � � �, , <br /> ���i����,�:�3���;,'��'i�i��1C�_ u ,� <br /> „ � , a ,, �. P��. <br /> : � , . � „ <br /> •. �t xa�ti�. : <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 $ 5.00 <br /> Mail-In Fee(If Applicable) $ 2.00 <br /> Total Permit Fee $ <br /> (Permit Fees Conrinued On Next Page) <br /> 2 <br />