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� • . <br /> PLUMBING FIXTURES BEING'INSTALLED <br /> FIXTURE BSMT l� � 2` OTHER FIXTURE �� BSMT 1 ' 2� OTHER <br /> TYPE FL FL TYPE FL FL <br /> Water Closet � � Floor Drains •� <br /> o� <br /> Lavatory % � Sewer Ejector <br /> Bathtub i r Laundry Tray <br /> { <br /> Shower Washer <br /> � f <br /> Kitchen Sink � � Water Heater / <br /> / <br /> Disposal � Water Softener / <br /> l <br /> Dishwasher � Wet Bar <br /> Sillcocks � Miscellaneous <br /> PERMIT FEE CALCULATION(S) <br /> BASED 4FF - 2002 STATE STATUE <br /> ❑ Yes,this section applies <br /> The replacement of a Residential fixture or ap lip �ance that meets all 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; excludinQ the cost of the fixture or appliance: and <br /> 3. Is 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 $ .50 <br /> Mail-In Fee(If Applicable) $ 2.00 <br /> Total Permit Fee $ <br /> (Permit Fees Continued On Next Page) <br /> 2 <br />