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� <br /> PLUMBING FT�TURES SEING INSTALLED <br /> FIXTURE BSMT 1 2 OTHER FIXT[JRE BSMT ls 2�`D OTHER <br /> TYPE FL FL TYPE FL FL <br /> Water Closet � /� 2 Floor Drains [�/ <br /> ct .� � <br /> Lavatory � � Sewer Ejector <br /> Bathtub I l La undry Tray ' � <br /> ! <br /> Shower ' ' � Washer <br /> � <br /> Kitchen Sink � Water Heater I <br /> Disposal � Water Sofrener I <br /> Dishwasher I Wet Bar ' <br /> Sillcocks �✓ Miscellaneous <br /> ✓ <br /> PERMIT FEE CALCULATION(S) <br /> BASED OFF - 2002 STATE STATUE <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 />