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06/18/2013 12:01 FAX 9529335049 CULLIGAN MNTKA 0 003 <br /> S <br /> `,', PLU1'�!IBX.N,Cr�I�TURE�BEING IriSTALI;�L?. . , <br /> FIXTURE BSMT 1ST 2ND OTHER FIXTURE BSMT 1ST 2'° 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 1 <br /> Dishwasher Wet Bar <br /> Sillcocks Miscellaneous <br /> P 'G' �' x9, ,,,.r. ...,_5r,�1+...;fit .;,, .. ,��, �r,',.iiii:,°.'j.j;14.i}j„�n'1+,9h�.,?fi;`y"�''„�h::.i?",�Mr!^ ,.5«'.tl: <br /> r i�T'Ss9 IU j'af Z{?kt Y u ,•�! 4 t J7r ' 1�t+l-%i.r �l� A.[' 4 e; k r a}�r i n it S�3 . <br /> } f5S yl�1 s,i '� � A 44� AI 3 i 1 �S t �'r ��,kit tl,vi.'�i. <br /> � " <br /> : r � <br /> ❑ Yes,this section applies <br /> The replacement of a Residential fixture or appliance that meets all three of the following requirements: <br /> 1. Does not require modification to electrical or gas service. <br /> 2. Has a total cost of$500.00 or less;excluding the cost of the fixture or appliance:and <br /> 3. Is improved,installed or replaced by the homeowner or licensed 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 />