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08-1 'I-14; 15� 38 ; 9522494616 ;7632950654 # 3/ 5 <br /> il <br /> ; ' �,PLUMB1��y'- ,��� - � '- S�BE�TG.TNSTAT�I,ED'�' <br /> _ -- <br /> FIXTURE BSMT 1'` 2"u � OTHFR FIXTURE BSMT-----1':'------2"�---� OTHER 1 <br /> TYPE FL TL TYPE �L FL � <br /> Water Closet Floor Drair�s ' <br /> L,avatvry Sewer Ejectm• <br /> Bathtub i Laun�ry T��ay <br /> Showcr Washer <br /> KilChen Sink I, Walcr Hct�tcr I I <br /> i <br /> Disposal Watcr Soficncr <br /> Di�hwasher Wet$ar <br /> Sillcocks i Miscellaneous <br /> I� <br /> � ' ,' ' , ?��� , �� ,s� � >, �, ��r'��r�;'.�E�ALCULATTQN(S�)� ::r� � - --- - ,�_! <br /> ,> , ,,,,; '� , �f , ;�AS$1'�,�,Ol�'� .2t1�2 STA'�E,.�'�l�,Z��'r -- — ' <br /> ❑ Yes,fliis section applics I I <br /> T�he replaceme�t of only one Rcsidential fixture o I that meets xll ttu�e of thc follnwing <br /> requirements� <br /> 1. Does 11Qt require modification to cicc� ical or gas Service. <br /> 2. Has A jg�al cost o�$500.00 or less;ex ludi the cost o�the fixture or appliancc:dnd <br /> 3. Is arzap►'oved, installed or rcplaeed b� e homeovtmer or licensed plumbing ccmtractor. <br /> Ski�next section,if this applies; i Cost of Aennit $ 15.OU <br /> State Surcharge $ S.O6 <br /> j Mail-In Fee(lf Appaicable) $ 2_00 <br /> I� <br /> Total��rmit Fee � <br /> (�ermlt l+ecs Contia�ued Utt Next Pa�e) <br /> I <br /> ; 2 <br /> � <br />