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S <br /> 1y I C L Z�. � 1;:"..1 L;� v,. Y 4 6 7, - <br /> -f”-r, `'1' rti,,.. .... ' ra: a ``- ._,..-..�..,, ,.,. .,,<..�....�._.1Ls.'� <br /> FIXTURE BSMT ls, 2ND OTHER FIXTURE BSMT ls' 2ND OTHER <br /> TYPE FL FL TYPE FL FL <br /> Water Closet i Floor Drains <br /> Sewer Ejector <br /> Lavatory I <br /> Bathtub Laundry Tray <br /> Shower Washer <br /> Kitchen Sink Water Heater <br /> Disposal Water Softener <br /> Dishwasher Wet Bar <br /> Sillcocks Miscellaneous <br /> .. <br /> I <br /> 1r \CI <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 /> $ 15.00 <br /> Skip next section,if this applies; Cost of Permit <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 />