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09/02/2015 14:�0 FAX 952�J3a5049 CULLIGAN hiNTI�A C�00� <br /> a � <br /> � ,�,�,,PL�LTNI��1�i Cr FI�TIC�'S`�E�NG�I�TST�i�T�E�' ��" <br /> .#;`,: _ � :r;J��,.� ��v�.. <br /> FIXTUR.E B5MT 1` ?' ' OTHER FIXTURE 6SMT 1' 2' OTI-IER <br /> TYPE �'L PL TYP� �'L F�, <br /> Water Closet Floor Drains <br /> �avatory Scwer Ejeaor <br /> Bathtub Laundry Tray <br /> Shower Washer <br /> � ! <br /> Kitchen Sin1c Water�-leater <br /> Disposal Water Softener � <br /> Dishwasher Wct Bar <br /> Sillcocks Miscel]aneous � <br /> l�d�.r....i��t1'�f��F, In �� � p�'�4I`�^�?�{; � ('T �1 ri �r � ! I`f II � ' <br /> �. Yj"��117_�, ���,( h ���" �� �.l'I 1ICJ.:J.1.L•�'���.���S'������1������17�,1. �� � � ' .I .I f 1� �1 Y�'If <br /> ; :� , BAS'EI7 Ql?�` ZOb2 SZ"AT'��TA�, � ' <br /> ,.,; , ,-,;,,� � �-; I',�arl <br /> ❑ Yes,this section applies <br /> The replacement of a Rcsidcntial fixturc or epplianCe thst meets all three ofthe following requirements� <br /> 1.., Does not require modification to electricaI or gas service: <br /> 2. Has atotal cost of��00.00 or less;excludin�the cost ofthe fixture or appliance:and <br /> 3. Ts improved;installed or replaced by the homeowner or lieensed eontractor. <br /> Skip ncxt section,if this applies; Cost of Pernlft $ 15.00 <br /> ` State Surcharge $ 5.00 <br /> Mail-In Fee(3f ApplicAble) � 2.00 <br /> Total Pcrmrt Fec � <br /> (Permif Fees Continued On Next Page) <br /> � <br />