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PLUMBING FIXTURES BEING INSTALLED <br /> FIXTURE BSMT lsi 2'�D OT�IER FIXTURE BSMT 1sT 2ND OTHER <br /> TYPE FL FL TYPE FL FL <br /> Water Closet ,� ,� � Floor Drains � 4 <br /> Lavatory 1 1 3 Sewer Ejector <br /> Bathtub ,) Laundry Tray 1 <br /> Shower � � Washer 1 <br /> Kitchen�ink ,� Water Heater ,� <br /> Disposal ,� Water Softener ,� <br /> Dishwasher ,� Wet Bar <br /> Sillcocks 3 Miscellaneous <br /> ( PERMIT FEE CALCULATION(S) <br /> BASED OFF - 2002 STATE STATUE <br /> ❑ Yes,this section applies <br /> The replacement of only one Residential fi�ure 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 />