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PLUMBING FLXT[.TRES BETNG INSTALLED ' <br /> FIXTURE BSMT 1 2 OTHER FIXTURE BSMT 1 2 OTHER <br /> TYPE FL FL TYPE FL FL <br /> Water Closet ^� Floor Drains <br /> U�, ( � �=� � <br /> Lavatory � � Sewer Ejector r <br /> � <br /> Bathtub 1 I Laundry Tray � <br /> � <br /> Shower I Washer � <br /> Kitchen Sink i Water Heater <br /> Disposal i Water Softener <br /> Dishwasher I Wet Bar <br /> Sil Icocks Miscellaneous <br /> � �r, , <br /> PERMIT FE� CALCULATION(S) � <br /> BASED OFF - 2002 STATE STATUE <br /> ❑ Yes,this section applies <br /> The replacement of a Residential fixture or appliance that meets all three of the following requirements: <br /> 1. Does not require modification to electrical or gas service. <br /> 2. Has a total cost of$500.00 or less;excludin�the cost of the fixture or appliance:and <br /> 3. !s imp:oved, iastzlled cr repluc�d by t���cm�e:��7e:c:licer.sed co�tracter. <br /> Skip next section,if this applies; Cost of Permit $ 15.00 <br /> State Surcharge $ .50 <br /> Mail-In Fee(If Applicable) $ 2.00 <br /> Total Permit Fee $ <br /> (Permit Fees Continued On Next Page) <br /> 2 <br />