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! <br /> ,�.,, <br /> FIXTURE BSMT 1 2 OTHER FIXTURE BSMT 1 2 OTHER <br /> TYPE FL FL TYPE FL FL <br /> Water Closet � � Floor Drains � <br /> Lavatory � Sewer Ejector <br /> Bathtub Laundry Tray / <br /> Shower P r Washer � <br /> / <br /> Kitchen Sink � Water Heater / <br /> Disposal j Water Softener <br /> � <br /> Dishwasher Wet Bar / <br /> Sillcocks � Miscellaneous <br /> O� <br /> PERMIT F£E C�.L.CC;I,ATION(S} - - - --_� <br /> BASED C,���-20�2 �'�..�.;I'� STATliE <br /> ❑ Yes,this section applies <br /> The replacement of only one Residential fixture 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;excludin�the cost of the fixture 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 Permit $ 15.00 <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 />