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� <br /> 1 <br /> PLUMBING FIXTURES BEING INSTALLED <br /> FIXTURE BSMT 1 2 OTHER FIXTURE BSMT I 2' OTHER <br /> TYPE FL FL TYPE FL FL <br /> Water Closet �� � � Floor Drains � <br /> Lavatory n � � � Sewer Ejector <br /> fi� <br /> Bathtub �� � Laundry Tray <br /> Shower i Washer <br /> Kitchen Sink � Water Heater � <br /> Disposal � Water Softener <br /> Dishwasher ' Wet Bar <br /> Sillcocks I Miscellaneous <br /> PERMIT FEE CALCULATION(S) � � <br /> BASED OFF - 2002 STATE STATUE <br /> ❑ Yes,this section applies <br /> The replacement of only one Residential fixture ar 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]ess; 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 />