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PLUMBING FIXTLTRES BEING INSTALLED <br /> � FIXTT�J&E �� BS1�fT � 1'�� � 2:�' ' OTI-3ER �� �I?�TU�I�E �� B�Sl�T � �''� � 2,�� �� f�TiIEY� ��� <br /> TYPE FL FL TYPE FL FL <br /> Water Closet � � � Floor Drains � <br /> Lava�rnry / / � 5ewen�j�ec�mr <br /> , Bathn�� i , � , Laundry Tray , i � ! i <br /> Shower ' Washer / <br /> Kitchen Sink � Water Heater � <br /> Dis�p�sa� / 'ti'Vat�er'Sc�ftca�er <br /> D1S11WaShP�:' � i � i W0i B�uL i � � � i i <br /> Sillcocks Miscellaneous <br /> � <br /> 2jo <br /> PERMIT FEE CALCULATION(S) <br /> � � R 1 C�.'F"1 (�l�F' _ '� /��1'���T�TF �T�TT��'�F: � <br /> I Ll 1��r y�,�_V \✓1 ,i,�l,lw:.�-V A:�.,f J 1/ Ld <br /> ❑ Yes,this section applies <br /> The replacement of only one Residential fixture or ap�liance that meets all three of the following <br /> requircr�ents: <br /> I. Does not require modification to electrical or gas service. <br /> 2. Has a totaP cost af�50().df�or tess;excPud'in�Che ecrst oP'tP�e�xt�re or appFian�ce: and <br /> 3. Is zir_rrove`,:i�sta!'e� �*r r�-Y1ae,ed Ly:.ze':���e�w��:or l:c�::sed pl�;:zb�i�a e�a�ti-u���r. <br /> Skip next section, if this applies; Cost of Permit $ l 5.00 <br /> State Surcharge $ 1.00 <br /> Mail-In Fee(If Applicable) $ Z.00 <br /> Tatal Ferm�f Fee � <br /> (Permit Fees Continued On Next Page) <br /> 2 <br />