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' 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 I I 3 Floor Drains l <br /> Lavatory � � � Sewer Ejector <br /> Bathtub z Laundry Tray 1 <br /> Shower � 1 Washer � <br /> Kitchen Sink � Water Heater / <br /> Disposal ' Water Softener <br /> Dishwasher � Wet Bar , <br /> Sillcocks Z Miscellaneous <br /> �PERI�IIT FEE CALCULATION�S) � � � �� <br /> BASED OFF - 2002 STATE STATLTE <br /> ❑ Yes,this section applies <br /> The replacement of only 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; excludin�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 $ 1.00 <br /> Mail-In Fee(If Applicable) $ 2.00 <br /> Total Permit Fee $ <br /> (Permit Fees Continued On Next Page) <br /> 2 <br />