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07/03/2013 12:45 FAg 9529335049 CULLIGAN �NTRA �J003 <br /> •r.; • �.r:+ '' '•. ' ' �'�`� ..µµ,, °�'�t� dJ,�,1I�3�•;•/i►1:i3�+�W,!a�-,��i"` . y:":,'.y.+. <br /> •,')�; ,�n^•77'��b�'�+�`�`��,1�'L�.' ..P i e •�+}w•�� "°�`t:' <br /> `.;,. ��r.. <br /> FI}(TiJRE BSMT 1 2 OTHER FIXTURE BSMT �,L FL O��R <br /> Typg FL FL 'I'YI'E <br /> Water Closet Floor Drains <br /> Lavatory Sewer Ejector <br /> B��b . Laundry Tray . <br /> Shower W�h� <br /> Kitchen Sinlc Wa#er Heater . <br /> Disposal Water 5oftener + <br /> � <br /> Dishwasher w�B� <br /> Sillcocks Miscellanaous <br /> 1 ` y � � ��. •: ` . 1 j.. `'.. .{i� L• �`Y:� i �'�'p N.. 1''ly 4 <br /> � ,}�g �3C" ir �I` 9r ��«y ,1 at+W+��°'�� �L�{ y, <br /> ' `�, �`l��•J+.�i���� y�.d6 ��•a •�U��Tr•�J�+��w.li i��i'IJi��d�a.��t'! <br /> r <br /> �.Y.'�.� t..nr t" . <br /> ❑ Yes,this section applies <br /> The replacement of a Residential f�ctu or a liance that meets all three of the followieg requirements: <br /> 1. Does not requira modification to elecirical or gas service. <br /> 2, Has a otal co of$SQ0.00 or less;excludins the cost of the fiycture or appliance:and <br /> 3. is improved,installed or replaced by the homeowner or licensed conlractor. <br /> Skip next section,ifthis applies; Cost of Permit $ 15.00 <br /> State Surcharge $ 5.00 <br /> Mail-In Fee(If Applicable) � 2.Q0 <br /> Total Permit Fee $ <br /> (Permit Fees Continaecf On Next Page) <br /> 2 <br />