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�� <br /> �� "��-� � ` �aa.�r ' �_ `,,. - a,'� »� �� � <br /> tw4" ,� � '�` =�x�' , , _,.� .. .. 2. '� �a� �S� ;:.� `r",', <br /> � ���t ;�.s „�" y, �.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 1 Sewer Ejector <br /> Bathtub / Laundry Tray <br /> l <br /> Shower l Washer <br /> Kitchen Sink Water Heater <br /> Disposal Water Softener / <br /> r ze/L <br /> Dishwasher Wet Bar <br /> Sillcocks Miscellaneous <br /> ;;;� �,�;:: <br /> � � �� ,�.�.. <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;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 />