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,�'L���'f��'��`�:�'��C��'�'��E� <br /> FIXTITIZE BSivfl' 1' 2 OTHER rIXTtJRT' BSM1' 1' 2 01'HF,R <br /> 'I'YI'E FL FL TYPE F1, Fi, <br /> Water Closet r Floor L?rains <br /> � <br /> Lavatory � Sewer I:jector <br /> Bathtuh , Laundry 'Tray <br /> i <br /> Shower Washer <br /> Kitchen Sink Water Heater <br /> Disposa] Water Softener <br /> Dishwasher Wet F3ar <br /> Sillcoc;ks Misc;ellaneous <br /> �'ERMIT FEE CALCULATEON(S) <br /> ' BASED QFF-20(32 STATE STATUE <br /> ❑ Yes,this section applie, <br /> "I'he replacement of a Residential fixture or appliance ihat meets ail three of the following requirements: <br /> 1. Does not require moeiificatic>n to eleetncal or g�s service. <br /> 2. I-ias a total cost of$5(�.IX)or less;excludin�the cast of the fiature or appliance: and <br /> 3. Is improved,installed or replaced by the homeown�,sr or licensed uwntractor. <br /> Skip neat section,if this applies; Cost of Permit $ I 5,(� <br /> State Surcharge $ 50 <br /> Mai]-In Fee(If Applicahle) $ 2.00 <br /> Total Permit Fce $ <br /> (Permit Fees Continued On Next Page) <br /> 2 <br />