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r � <br /> � � � <br /> , , � ,� <br /> .�;���'��.��•�.6;�_���� '�, �. '.` ,... ..' . .._. � x� �.. �� <br /> . � � . <br /> , <br /> �� .� �� °; �. .. , <br /> , , <br /> � . ,_. ,., ,. .. ..� .Y . ... <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 Washer <br /> Kitchen Sink � Water Heater <br /> Disposal � Water Softener <br /> Dishwasher � Wet Bar <br /> Sillcocks Miscellaneous <br /> ❑ Yes,this section applies <br /> The replacement of oniy one Residential fixture or appliance that meets all three of the following <br /> requirements: <br /> 1. Does not require modification to electricai 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 />