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� <br /> w � <br /> PLUMBING FIXTURES BElNG 1NSTALLED � <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 i Washer <br /> Kitchen Sink Water Heater <br /> Disposal Water Softener <br /> Dishwasher Wet Bar <br /> Sillcocks Miscellaneous <br /> � PERMIT FEE CALCULATION(S) � <br /> � � ��� BASED OFF - 2002 STATE STATUE � <br /> Y <br /> ❑ es,this section apphes <br /> The replacement of only one Residential fixture or ap lipp ance that meets all three of the following <br /> requirements: <br /> 1. Does not require mod�cation 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 licensed plumbing contractar. <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 />