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� ' <br /> :i�„�i s� ���:� =�x���x�r-��������z�sx��c,i; _� s .3 �4Y���� <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 I Wet Bar <br /> Sillcocks Miscellaneous <br /> '� Y y P ]�,-�.-�`rF �:�z �`'� � �a�� ��� �4 . ����f�.�� C x�� ��£ ���� <br /> ��i",o-�.�,i�.�tM'� �� . w5` aP y�,a r #•�„ :�sPF1� �� �, }s.��� ;� r ia`j � �� t.�j�� a <br /> ¢': ��`S"/ J d f y .r�' `A <br /> :� �� '�`�f-r�:'�*,�� °$A��D_� �-� ��T�� ���'.A�> � � �� ���.�� ��.} <br /> ; .. . .. . . <br /> Gm .�;, , ._ , _ ,.:. �� . . . . . <br /> ❑ Yes,this section applies <br /> The replacement of only one Residential fixture or appliance that meets all tluee 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 $ 1.00 <br /> Mail-In Fee(If Applicable) $ 2.00 <br /> Total Permit Fee $ . <br /> (Permit Fees Continued On Next Page) <br /> 2 <br />