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PLUMBING FIXTURES BEING INSTALLED <br /> FIXTiJRE BSMT ls 2ND OT�IER FIXTURE BS1�IT 1 r 2YD 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 a er Heater � <br /> Disposal Water Softener <br /> Dishwasher Wet Bar <br /> Sillcocks l�iiscellaneous <br /> PERMIT FEE CALCULATION(S) <br /> BASED OFF -2002 STATE STATUE <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 no?require modification to electrical or gas service. <br /> 2. Has a total cost of$500.00 or less; excludin�the cost of the fiYture or appliance: and <br /> 3. Is improved, installed or replaced by the homeowner or licensed plumbing contractor. <br /> Skip nert section,if this applies, Cost of Permit $ 15.00 � Jv�l�� <br /> State Surcharge $ .e�I 00 <br /> Mail-In Fee(If Applicable) $ 2.00 <br /> Total Permit Fee � •� �j�j_G 0 <br /> � (Permit Fees Continued On Next Page) <br /> 2 <br />