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O1/28/2014 12:58 FAX 9529335049 CULLIGAN MNTKA C�003 <br /> I <br /> ' '��P�,��vl$.�'Q;,��TLT,�t�S BEINQ,YNSTAT�i,ED ' <br /> FIXTURE BSMT 1 2 OTHER FIX'I'URE BSMT 1 2 OTHER <br /> TYPE FL FL TYPE FL FL <br /> Water Closet Floor Drains <br /> Lavatory Scwer Ejector <br /> Bathtub Laundry Tray <br /> Shower Washer <br /> Kitchan Sink Water Heater <br /> Disposal Water Softener <br /> Dishwasher Wet Bv, ! <br /> Sillcocks Misceilaneous <br /> r � � � � �1i1\LVl��� '�+�^�^t7� �+7 �-{ r � � i a <br /> ;� ,� ,; L=rrtk.�l1L��Q 1-1�LV��� ' � a��.+`n� J�S.y�, '. �� ��'ypr�4>l�q <br /> i3ASEp 0�`�?' F��0.�1�STAI� STATU:E ` ,�.���k�rt����r r: }x�����:: <br /> .�ti,�t��: t�; ;�,,: <br /> ❑ Yes,this section applies <br /> The replacement of a esidential fiacture or appiiance that meets all threa 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;excludine the cost of the fixture or appliance: and <br /> 3. Is improved,installed or replaced by the homeowner or Iicensed contractor. <br /> Skip next section,if this applies; Cost of Permit $ 15.00 <br /> State Surcharge $ 5.00 <br /> Mail-In Fee(If Applicablc) $ 2,00 <br /> Total Permit Fee $ <br /> (Permit Fees Continued On Next Page) <br /> 2 <br />