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PLUMBING FIXTURES BEING INSTALLED ` <br /> FIXTURE I3SM�1� l�' Z"D O"1'IIER 1'1XTURE I�SMT l� 2 ° OTHEK <br /> TYPE FL FL TYPE FL FL <br /> Water Closet Floor Drains <br /> Lavatory Sewer Ejector <br /> E3athtub Laundry Tray <br /> Shower Washer <br /> Kitchen Sink Water Heater <br /> P,ispcsal '�'ater Soften�r <br /> Dishwasher e <br /> Sillcocks Miscellaneous <br /> PERMIT F�E C LCULA�I'IOI�(S) � � <br /> �__ � BASFD OFF - 20 2 STATE S"I"ATUr � � �� � <br /> ❑ Yes,this section applies <br /> The replacement of only one Residential fixture ar a liance that meets all three of the following <br /> requirements: <br /> 1. Does not require modification to electric 1 or gas service. <br /> 2. Has a total cost of$500.00 or less;exclu in the cost of the fixture or appliance: and <br /> 3. Is improved, installed or replaced by the omeowner or licensed plumbing contractor. <br /> Skip next section, if this applies; Cbst of Permit $ 15.00 <br /> St�te Surcharge $ 5.00 <br /> Ma�l-In Fee(lf Applicable) $ 2.00 <br /> TOtal Permit F'ee $ <br /> �1 <br /> (Permit Fees Continoed On Next Page) <br /> 2 <br />