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11/18/2014 14:02 FAX 95293a5049 CULLIGAN MNTKA f�003
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<br /> FI?CTURE BSMT 1 2 OTH�R FIXTURE BSMT 1 2 OT[-I�li
<br /> TYPE FL FL T�Y'PE FL FL
<br /> Watcr Closet Floor Drains
<br /> LavaSory Sewer Ejector
<br /> Bathtub Laundry Tray
<br /> 5hower �'�'��
<br /> Kitthen Sink Water Heater
<br /> Disposal Water Sof�ener I
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<br /> Dishwasher Wet Bar �
<br /> Sillcocks Miscellaneous
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<br /> ❑ Yes,this section applies
<br /> The replaccment of a E�esldential fixture or sppliance that meets a1l three of the following requirements:
<br /> 1. Does not require modi�tCstion to electrical or gas Service.
<br /> 2. Has a totaI cost of$500.00 or less;excludin the cost of the fixturc or appliance:and
<br /> 3_ Is improvcd, installed or replaced by the homeowner or licensed eontractor.
<br /> Skip next section,if this spplies; Cost of Permit $ I 5.0�
<br /> StAte Surcharge $ 5.00
<br /> Mail-In Fte(If Applicable) $ 2.OQ
<br /> Total Permit Feo $
<br /> (Permit Fees Continued On ivext Page)
<br /> 2
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