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< <br /> PLUMBING FIXTURES BEING 1NSTALLED � <br /> FIXTURE BSMT 15 2� OTHER FIXTURE BSMT 15 21VD 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 <br /> Disposal Water Softener <br /> Dishwasher Wet Bar <br /> Sillcocks , Miscelianeous <br /> PERMIT FEE CALCULATION(S) <br /> BASED OFF - 2002 STATE STATL7E <br /> ❑ Yes,this section applies <br /> The replacement of onty one Residential fixture or appliance that meets all three of the following <br /> requirements: <br /> 1. Does not require modification to electrical or gas service. <br /> 2. Has a total cost of$500.00 or less;cxcludin�the cost of the fixture or appliance: and <br /> 3. Is improved,installed or replaced by the homeowner or licensed plumbing contractor. <br /> Skip next section,if this applies; Cost of Permit $ 15.00 <br /> State Surcharge $ 5.00 <br /> Mail-In Fee(If App(icable) $ 2.00 <br /> Total Permit Fee �����C�; <br /> f-. <br /> . 4 <br /> (Permit Fees Continued On Next Page) <br /> RECEi��;�� � <br /> ` . , � ,� ��14 _ , r 2 . <br />