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10/17!2011 13:19 FAX 9529335049 CULLIGAN MNTKA C�003 <br /> '','` ; kli:��$:I�G.�'I�'I'�E�:.$��TG:11�5�'T�1LI��L1.; . � <br /> FIXTURE BSMT 1 2 OTHER FIXTURE BSMT 1 2 OTHER <br /> TYPE FL FL TYPE FL FL <br /> Water Closet Flo or 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 /> :r�:�•'�.,�4'�1x��,�F,��,{�l��a;;�S,;:�t.�.EF}r..k.r�(jY�a`4,�x �+'� �j .. . SI' 77� :�:(�•7t�is:,:.�,•r�„c�in;1'.�t j. I�4�.�[i� °�i �i <br /> si ,r� ,I 3 4r S �� 1��(� k 'a �1GJ�� ��ii�����.L����t.y �ti� `[� �! � p'Y,}i 1 ��� �° , A <br /> � i� � 1� �„z-�y "Fy �r r I ..� ' � S xrt., e ,� ¢P lf�i� 'r' �r� h p��"�qT ���'���' '� <br /> '1� � }' ��S �� ti �-.t �'}�3 /� � � ` i � ' ',i ' e. s i���' - �' � � <br /> �-�-a F �2�,n�C v!�11t, �.� s� � �Ll,����.9� -,���� �������� , ,1",'{ ,�_ 'i u N':t i Y� <br /> .i .� ..t.. <br /> � Yes,this section applies <br /> The replacement of a ReSidential fixture or ap�liance that meets all three of the foifowing requirements; <br /> 1. Doas not require modification to electrical or gas service. <br /> 2. Has a tota 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 contractor. <br /> Skip next section,if this applies; Cost of Permit $ 15.00 <br /> State Surcharge $ 5.00 <br /> Mail-In Fee(If Applicable) $ 2.00 <br /> Total Permit Fee $ <br /> (Permit Fees Continued On Next Page) <br /> 2 <br /> I � <br />