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� <br /> �=`���4�;���,���,,� ��;`�������-z�'I�MB'�G�I��T''�L7RES'BETNG IlVSTALLED.�;: `k���.,��,�� ��;��,3��Rz;;§ . <br /> FIXTURE BSMT 1 2 OTHER FIXTLJR.E 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 I <br /> Disposa! Water Softener <br /> Dishwasher Wet Bar <br /> Sillcocks Miscellaneous <br /> PERIVIIT FEE CALCULATION(S) `' <br /> BASED OFF - 2002 STATE STATUE <br /> ❑ Yes,this section applies <br /> The replacement of a Residential fixture or appliance 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 Yhe cost of;he f xti;re 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 />