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, �,,,.,,., �, :LE.D.- , . � �. <br /> FIXTUkE BSMT 1 2 OTHER FIXTURE sSMT 1 2 OTHER <br /> '1'XPE FL FL TYPE FL FL <br /> Water�loset Floor Drains <br /> Lavatory Scwe�Ejector <br /> Bathroom Laundry Tray � <br /> Shower washcr <br /> � <br /> Kitchen Sink Water kleater <br /> Disposal Wacer Softener <br /> Dishwashcr We[Bar <br /> Sillcocks Miscellaneous <br /> 1(,c,lo � <br /> , �.: ,, <br /> ' , � . � ,,.;`��R�T.T<FEE�CA�.CCJL�TION(S) <br /> � BASED`�OFF`=�2002�STATE~STATUE <br /> ❑ Ycs,this Sec(ion applies <br /> The replacement of a ge�dcntial fixture Q,«p, li� ance that rr�eets all three of tlte following requiremaus: <br /> 1. Does not requirc modification to cicctrical or gas sei'Vice, <br /> 2. F�as a total cost of$5�0.00 or less; c in the cost of the Gxturc or�ppliance: and <br /> 3. Is improved,installed or replaced by che homeown�r or licensed concractor. <br /> Skip pext section, if this app(ies; Cost of Permit $ 15.00 <br /> State 5urcharge $__,�_,__50 <br /> Mail-!n Fee(If Applicable) $ 1.SQ <br /> Total Permit Fee S <br /> (Permit�ees Continued On Next Pxge) <br /> 2 <br />