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r <br /> � <br /> t <br /> , <br /> , s� '� <br /> ��� ���� �'����t44,�";di knl t ��.���k_���"�� F � 1�����``�'��.wt§e'��°Y"�* rY e ,,a, ,§.`' <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 /> .s_ . <br /> �, ��,� �: <br /> : �,��, � � ; _ . � � ,� <br /> m .� ��� � � � <br /> � <br /> � , , , _ _ <br /> �� �- � .,:.� �� < <br /> . � �����_U � �,�_ � t ���_. ,.� . .4.�. _ � • <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;excludinQ 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 $ I5.00 <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 />