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� <br /> PLUMBING FIXTURES BEIN INSTALLED <br /> FIXTURE BSMT l� � 2�D OTHER FIXTU E BSMT l�� 2'�' OI�fIER <br /> TYPE FL FL TYPE FL FL <br /> Water Closet Floor D ains <br /> Lavatory Sewer 'ector <br /> Bathtub Laund Tray <br /> Shower Washer <br /> Kitchen Sink Water eater <br /> Disposal Water ftener <br /> Dishwasher Wet Ba _ <br /> Silicocks Miscell neous <br /> 1-Iron filter <br /> PERMIT FEE CALCUL TION(S) <br /> BASED OFF -2002 STA STATUE <br /> ❑ Yes,this section applies � <br /> The replacement of only one Residential fixture or appliance t at meets all three of the following <br /> requirements: <br /> 1. Does not require modification to electrical or gas ervice. <br /> 2. Has a total cost of$500.00 or less;excludin�the ost of the fixture or appliance:and <br /> 3. [s improved, installed or replaced by the homeow er or licensed plumbing contractor. <br /> Skip next section, if this applies; Cost of rmit $ 15.00 <br /> State Sur harge $ 5.00 <br /> Mail-In ee(If Applicable) $ 2.00 <br /> Total Pe mit Fee � <br /> (Permit Fees Continued On Next Page) <br /> 2 <br />