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07/08/2013 11:53 FAX 9529335049 CULLIGAN MNTKA �j003 <br /> � �PT,C1Iv1��NCrFIXTU.R��BEINGIl�tST'1�'LET) . ,'��' <br /> FIXTURE BSMT 1 T 2 OTHER FIXTURE BSMT 1 2 OTHER <br /> TYPE FL FL TYPE FL FL <br /> Water Closet Floor I�rains <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 /> Silicocks Miscellaneous <br /> �,;��� ��z� t ���,�; r �� prRMrr��E cA���;A�zo�{s) � r�t � � ��;�' � <br /> , �.����n o�-�oo� s�t�.T�s��� - ti � <br /> -� ,, � , , ; � r � <br /> :.:��Fti,�, j,,�����N'')`I�; , - i r�� t tt ,a�,`,��.;' <br /> 'it? — <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 reyuire modification to elecirical or gas service. <br /> 2. Has a total cost of$500,00 or less;excludin�the cost of the fixture or appiiance:and <br /> 3. Is improved,installed or replaced by the homeowner or licensed eontractor. <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 />