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06/11/2013 11:45 FAX 9529335049 CULLIGAN MNTKA C�003 <br /> PIrIIMBINGFIXTIJ,RES BE�TG�STALLED � <br /> FIXTURE BSMT 1 T 2 OTHER FIXTUI2E BSMT 1 T 2 OT'HER <br /> TYPE FL FL TYPE FL FL <br /> Water Closet Floor Drains <br /> Lavatory Sewer Ejector <br /> Bathtub Laundry Tray <br /> Shower W asher <br /> Kitchen Sink Water Heater <br /> Disposal Water Softener � <br /> Dishwasher Wet Bar <br /> Sillcocks Miscellaneous <br /> � �;t a � <br /> � '��� ` , '�.� �' ������ � � � P�RM7T;��`FE'CAL�L'T;�A7'�Q�v`(S) '� � "`� ';���`��� ���� <br /> ���i,�;;,,k,�4;��a�','���` ���°' ..�,�;- T�A�ED�OFF _2002 S'TATE 5T�ITLTE�.�';�' t , �� '�'�'�.' a` `�,;�_���xa, <br /> ❑ Yes,this saction applies <br /> The replacement of a Residential fi�cture or appliance that meets all three of the following requirements; <br /> 1. Doas not require modificaTion to alectrical or gas service. <br /> 2. Has a total cost of$Sd0.00 or less;excludin�the cost of the fixture or appliance:and <br /> 3. Is improved, installed or replaced by the homeowner or licansed contractor. <br /> Skip next section,ifthis 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 />