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05/13�2015 1,2:24 Fal 9529�35049 CULLIGAN MNTKA C�00�
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<br /> � 4 P�'lJ'�1�51��-F1.'�TT�R�S"'� �TG��NS
<br /> �IXTUK� H5M7 1 2 OTH�R F[XTURE BSMT 1 2 OTHER
<br /> TYPE FL FL TYP� FL FL
<br /> W ater Closet Floor Drains �
<br /> Lxvatqry Sewer EjeCtor �
<br /> BaChtub Laundry Tray
<br /> Showcr W asher
<br /> K,itchen 5lflk Watcr Heater
<br /> �isposal Watcr 5ofrener �
<br /> bishw�sher Wct Bar
<br /> 5illcocks Miscellaneous
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<br /> �'r � � �r'° b`� �� ,.' ' �. ,,`BA;�ED O�'F _.2�b�s ��f�xE STAT�.:� � � a
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<br /> ❑ YcS,ihis section applies
<br /> 7'he r�plscement of s Residential fixture or a ]iance that mects all three of the following rcqqil'ements�
<br /> 1. Does not require modi�ication lo electrical or gas service.
<br /> 2. �Sas a total cost o�$�00.00 or less;excludin�the cost of the�xture or appliance:and
<br /> 3. Is improved,installcd or replaccd by the homeowner or licensed eontr�actor.
<br /> Skip next soction,ifthis applies; Cost of Permit $ 1_�
<br /> $tatc Surcharge $ 5.00
<br /> Mail-In Fee(IfApplicable) $ 2,QQ
<br /> Total�'ermit Fee �
<br /> (permit Fees Continued On Nex�t Page)
<br /> 2
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