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PLUMBING FIXTURES BEING INSTALLED <br /> FIXTURE BSMT 1 T 2" OTHER FIXTURE BSMT ls 2ND OTHER <br /> TYPE FL FL TYPE FL FL <br /> Water Closet � � Floor Drains I � <br /> � <br /> Lavatory I � Sewer Ejector <br /> Bathtub Laundry Tray j <br /> � <br /> Shower � I Washer � <br /> Kitchen Sink n Water Heater I <br /> �C <br /> Disposal Water Softener <br /> Dishwasher Wet Bar l <br /> Sillcocks /�, Miscellaneous I <br /> � � <br /> PERMIT FEE CALCULATION(S) <br /> BASED OFF - 2042 STATE STATUE <br /> ❑ Yes,this section applies <br /> The replacement of only one Residential fixture or appliance that meets all three of the following <br /> requirements: <br /> 1. Does not require modification to elech-ical 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. ls 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 $ 1.00 <br /> Mail-In Fee(If Applicable) $ 2.00 <br /> Total Permit Fee $ <br /> (Permit Fees Continued On Next Page) <br /> 2 <br />