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06/28/2012 11:11 7634752566 PAGE 03/05 <br /> FLXTURE BSMT 1'4-' 2 OTHER FIXTURE BSMT 1 2 NU 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 Wet Bar <br /> Sillcocks Miscellaneous <br /> P�I> - <br /> Ztir�„�toz-•. <br /> x <br /> ❑ Yes,this section applies <br /> The replacement of only one&Midential fixture o_r a liance that meets all three of the following <br /> requirements: <br /> 1. Does no require modification to electrical or gas service. <br /> 2. Has a o c t of$500.00 or less;excludin 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 Foe(If Applicable) $ 2.00 <br /> Total Permit Fee $ <br /> (Permit Fee%Continued On Next Page) <br /> 2 <br />