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. 04/07/2014 14: 16 FAX 9529335049 CULLIGAN MNTKA �006 <br /> � <br /> " ;PLi�3 �.. L� <br /> IN.: � , TLIRES-°BEIl�I�r.I�iS`'t',�L�E <br /> FIXTURE BSMT 1 2 OTHER FIXTURE BSMT 1 2 OTHER <br /> TYPE t'L FL TYPE FL FL <br /> Water Closet Floor Drains <br /> Lavatory Sewer Ejector <br /> Bathtub Laundry Tray <br /> Shower Washer <br /> Kitchen Sink Water Heater <br /> Disposal Water Softener <br /> Dishwasher Wet Bar <br /> Sillcocks Miscellaneous <br /> �`'" � �'E�'h�T��'�E " ��, <br /> s � '�fiJIIA;TTt7Iv`(S) �f , °4 , ,� <br /> � `` '�AS�ia��F=20t�� �`TAfiE S�'.AT(.1� ;��,'' u tx� '�` <br /> ❑ Yes,this section applies <br /> The replacement of a Residential fixture or a liance that meets sil three of the following requirements: <br /> 1. Does not require modification to electrical or gas service. <br /> 2. Has a total cost of$500.00 or less;excludine the cost of the fixture or appliance:and <br /> 3. [s improved, installed or replaced by the homeowner or licensed 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 /> Tota!Permit Fee $ <br /> (Permit Fees Continued On Next Page) <br /> 2 <br />