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� <br /> PLI7MBING FIXTL)RES BEING INSTALLED <br /> FIXTURE BSMT 1 2 OTHER FIXTURE BSMT 1 2 OTHER <br /> TYPE FL FL TYPE FL FL <br /> Water Closet � i Floor Drains <br /> Lavatory S I Sewer Ejector <br /> � <br /> Bathtub Laundry Tray I <br /> snoW� i w�n� <br /> Kitchen Sink � Water Heater <br /> Disposal � Water Softener <br /> Dishwasher I Wet Bar i <br /> Sillcocks Miscellaneous <br /> PERMIT FEE CALCULATION(S} <br /> BASED OFF - ?00? STAT'E STATUE <br /> ❑ Yes,this section applies <br /> The replacement of only o�Residential fi�cture 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;excludine the cost of the fi�cture 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 Perrnit $ 15.00 <br /> State Swcharge $ 5.00 <br /> Mail-In Fee(If Applicable) $ 2.00 <br /> Total Permit Fee $ <br /> (Permit Fees Contioued On Next Page) <br /> 2 <br />