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y <br /> ' I <br /> ` PLUMBING FIXTURES BEING: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 /> / <br /> Lavatory Sewer Ejector <br /> j y 3 <br /> Bathtub Laundry Tray � <br /> / �— <br /> Shower J W asher / <br /> 1 <br /> Kitchen Sink � Water Heater � <br /> Disposal � , Water Softener <br /> Dishwasher ! Wet Bar <br /> Sillcocks � Miscellaneous <br /> PERMIT FEE CALCULATION(S) <br /> ' BASED OFF - 2002 STATE STATCTE ` '' � � <br /> ❑ Yes,this section applies <br /> The replacement of a Residential fixture or appliance that meets all three of the following requu�ements: <br /> 1. Does not require modification to electrical or gas service. <br /> 2. Has a total cost of$�00.00 or less; excludin�the cost of the fixture or appliance: and <br /> 3. Is improved,installed or replaced by the homeowner or licensed contractor. <br /> Skip next section, if this applies; Cost of Permit $ 15.00 <br /> State Surcharge � .50 <br /> Mail-In Fee(If Applicable) $ 1.50 <br /> Total Permit Fee $ <br /> (Permit Fees Continued On Next Page) <br /> 2 <br />