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* . <br /> �� �`�����������`,�;'�"�'�: �� ' � .:.. f� BEING INS��LL�D��'.� � ���^����t` � �.. <br /> FIXTURE BSMT 1 2 OTHER FIXTURE BSMT 1 2�' OTHER <br /> TYPE FL FL TYPE FL FL <br /> Water Closet / � Floor Drains / <br /> Lavatory j �f Sewer Ejector <br /> / <br /> Bathroom Laundry Tray / <br /> Shower / / Washer 1 / <br /> / <br /> Kitchen Sink • f Water Heater <br /> � <br /> Disposal Water Softener <br /> Dishwasher � Wet Bar <br /> � <br /> Sillcocks � Miscellaneous <br /> � PERMIT�FEE CALCULATION(S) <br /> BASED OFF - 2002 STATE STATliE <br /> ❑ Yes,this section applies <br /> The replacement of a Residential fixture or apvliance 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;excludin�the cost of the fixture 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) $ 1.50 <br /> Total Permit Fee $ <br /> (Permit Fees Continued On Next Page) <br /> 2 <br />