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� <br /> R <br /> .y ,,.. ,y � a�_. .-r .. � ...�" _ �s <br /> 't� �l���l" ���' �Yi �2..�� >.,i ��� ��,. �� ����� ��R <br /> � r � <br /> N + <br /> ` <br /> w " <br /> , ,� <br /> ��� .._. .,.,. 1n „ s: , . � ...:.: „ .u,.r �: � �,, <br /> � <br /> _ �..�b� <br /> FIXTURE BSMT 1 2 OTHER FIXTURE BSMT 1 2 OTHER <br /> TYPE FL FL TYPE FL FL <br /> Water Closet l Floor Drains <br /> Lavatory , Sewer Ejector <br /> Bathtub ` Laundry Tray I <br /> Shower Washer <br /> Kitchen Sink Water Heater <br /> Disposal Water Softener <br /> Dishwasher Wet Bar <br /> Sillcocks Miscellaneous <br /> � <br /> , , <br /> a;� � � , � .. �� <br /> �u u�. ,. ,d�� <br /> ❑ Yes,this section applies <br /> The replacement of only one Residential fixture or a�pliance that meets all fhree 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 l�Iext Page) <br /> 2 <br />