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� <br /> s ` PLUMBING FIXTURES�BEI�I�TNSTAT:�ED;, <br /> FIXTURE BSMT I' 2' OTHER FIXTURE BSMT 1` 2' OTHER <br /> TYAE FL FL TYPE FL FL <br /> N�ater 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 /> � <br /> Siilcocks Miscellaneaus <br /> ,' PERIV�C��EE C�I,�C�TLAT�IOI�T�S} °: - <br /> t BASEI?OFF`=�20(?2�S'I`A'TE STA'TIIE ' <br /> ❑ Yes, is section applies <br /> The replacement of on e Residential tixture or an�liance that meets all ree- e foUowing <br /> requirements: <br /> 1. Dces not require modifica" to el ' al or gas service. <br /> 2. Has a total cost of 5500.00 0 •excludin the cost of the fixtore or apptiance:and <br /> 3. ls improved,installed placed by homeowner or licensed plumbing contractor. <br /> Skip next on,if this applies; Cost o it S I5.00 <br /> State Surchar $ 5.00 <br /> __ �..- Mail-[n Fee(tf Ap licable) $ 2.00 <br /> Total Permit Fee� � <br /> (Permit Fees Continued On Next Page) <br /> 2 <br />