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' . <br /> PLIJMBING FIXTURES BEING INSTALLED <br /> FIXTURE BSMT 1 2 OTHER FIXTURE BSMT 1 2 OTHER <br /> TYPE FL FL TYPE FL FL <br /> Water Closet / a 3 Floor Drains � <br /> Lavatory ' a 5 Sewer Ejector <br /> Bathtub � Laundry Tray <br /> � <br /> Shower � � Washer � ( <br /> Kitchen Sink � Water Heater i <br /> I <br /> Disposal j Water Softener <br /> Dishwasher � Wet Bar � <br /> Sillcocks 2 Miscellaneous <br /> � PERMIT FE�CALCULATION{S) <br /> BASED OFF - 2002 STATE STATUE <br /> ❑ Yes,this section applies <br /> The replacement of only one Residential fixture or a�pliance 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;excluding the cost of the fixture or appliance: and <br /> 3. Is improved, installed or replaced by the homeowner ar licensed plumbing contractor. <br /> Skip next section, if this applies; Cost of Permit $ 15.00 <br /> State Surcharge $ 1.00 <br /> � Mail-In Fee(If Applicable) $ 2.00 <br /> Total Permit Fee $ <br /> (Permit Fees Continaed On 1�Text Page) <br /> 2 <br />