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'w <br /> FIXTURE BSMT 1 2 N11 OTHER FIXTURE BSMT 1 2 ND OTHER <br /> TYPE FL FL TYPE FL FL <br /> Water Closet ! n Floor Drains ' <br /> Lavatory / o Sewer Ejector <br /> Bathtub 1 Laundry Tray r <br /> Shower ' Washer <br /> Kitchen Sink Water Heater / <br /> Disposal I Water Softener <br /> Dishwasher Wet Bar <br /> Sillcocks !) Miscellaneous <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;excludiniz 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 />