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f <br /> • �� <br /> �.F s PLUMBING FIXTURrS BEING INSTALLED <br /> FIXTURE BSM"1' 1�� 2ND OTHER FIX"I'URE i3SM'1' 1�� 2" OTHER <br /> TYPE FL FL TYPE FL FL <br /> Water Closet Floor Drains <br /> Lavatory Sewer Ejector <br /> Bathtub Laundry Tray <br /> Shower Washer <br /> Kitchen Sink Water Heater 1 <br /> Disposal Water Softener <br /> Dishwasher Wet Bar <br /> Sillcocks Miscellaneous <br /> � � . PERMt"I, FEE CALCULATION(S) � �� � � � <br /> � � ��� '�. BASI;D OFF — 2002 STATE S"TATU� � <br /> ❑ Yes,this section appl� <br /> The replacement of only one Reside tial fixture or a liance that meets all three of the following <br /> requiremerts: <br /> 1. Does not require modification electrical or gas service. <br /> 2. Has a total cost of$500.00 or les • excludin�the cost of the fixture or appliance: and <br /> 3. ]s improved, installed or replaced b the homeowner or licensed plumbing contractor. <br /> Skip next section, if this applies; t of Permit $ 15.00 <br /> State urcharge $ 5.00 <br /> Mail-In (If Applicable) $ 2.00 <br /> Total Permi ee $ <br /> (Permit Fees Continued On Next Page) <br /> 2 <br />