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ll/21/�011 16:23 FAX 9529335049 CULLIGAN MNTKA C�003 <br /> ; :;.: �. , .. <br /> . , ,.. ... :..::� ����i�;nJ�����ilx�s B�n�G:T�rs��r::L��; <br /> ;7. <br /> FIXTURE BSMT ] 2 OTHER FIXTURE BSMT 1 2 OTHER <br /> TYPE FL 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 /> t��t�1f,y,j�S.{+�''S'r *�i'�x 1 ji{trE^Li(�s� �� ..0 ��,l.y.A✓L V ' �l.a�� � �+'h ' i af rvx % ' t 'tr i +� <br /> ct li v3 zF� i .fi ^ tl �t �.'. �� �,i� t ii �� � n i�i � 5 rr�M'"�,�+1 k�YL y i �,���57� K�r <br /> m'��..�`�jl�r�lkV"1�.��_�' i �,, .F�" ' 3 '7Cn�!.��,hr t /�ci �(°�I4p4v4 �l �k -iM3� �� 'f,�cs��� ���N h. ,ai�l� ��5', . <br /> !'.ri:�r:�':� i'i,�.��.J�+�.�." ^ '.:'ti,� .r�� � �i",[1x ��V�,rla�����'(�-�" ,..cc ,,.�a ?L-i,l=� "�, ,,,��n7v` , '4< <br /> �':�+ <br /> ❑ Yes,this section applies <br /> The replacement of a Residential fixture or apnliance 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;excluding the cost of the fixture or appliance: and <br /> 3. Is improved,insta[led or replaced by thc homeowner or licensed contractor. <br /> Skip next Section,if this appiies; Cost of Permit $ 15.00 <br /> State Surcharge $ 5.00 <br /> Mail-In Fee(lf Applicable) $ 2.00 <br /> Total Permit Fee S <br /> (Permit Fees Continued On Next Page) <br /> 2 <br />