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Oa.�19/2015 1a:53 FA� 9529335049 CULLIGAN MNTKA �00�
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<br /> FIXTUR� BSMT 1 2 QTHER FIXTUT� BSMT ] 2 O7'HER
<br /> TYPE FL FL T�'PE FL FL
<br /> Water Closet FIoor Drai�s
<br /> Lsvatory 5cwer�jector
<br /> Bathtub Laundry Tray
<br /> Shower W�her
<br /> Kitchen S1nk Water Hcater
<br /> rlisposal Water Softener
<br /> Dishwashcr Wet Bar
<br /> Sillcocks Miscellaneous
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<br /> ❑ �Yes,this section applles
<br /> The replaccment af a Residential fixture or a liance that meets all three of the following rcquirements:
<br /> l. Does not require modification to e)eetrieal or gas service.
<br /> 2. Has a total cost of$500.00 or less;excludin�the eost of the fixture or appliance:and
<br /> 3. Is improvec], installed or raplaeed by the homeowner or licensed contraewr.
<br /> Skip ncxt sectipn,if this applies; Cost of Permit $_ 15.00
<br /> State 5urcharge $�pp
<br /> Mail-1n Fee(1f Applicable) $ 2.00
<br /> Total�e�r�tit Fee �
<br /> (Permft�'eC5 Continued On Next Page)
<br /> 2
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