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�-- PLIJMBING FIXTURES BE[NG INSTALLED <br /> FIXTURE aSM'i' 1' 2 OTHER FIX"1-URE BSN1"I' l� 2�� OT'HER <br /> TYPE FL FL TYPE FL FL <br /> Water Closet �loor Drains <br /> Lavatory Sewer Ejector <br /> Bathtub Laundry Tray <br /> Shower Washer <br /> Kitchen Sink � Water Heater <br /> Disposal � Water Softener <br /> Dishwasher i Wet Bar <br /> � <br /> Sillcocks Miscellaneous <br /> � � � � PERMIT FEE C"��1�CtJLATION(S} � � � <br /> � �� � BASED�FF -2002 STATE STATUE � � � <br /> ❑ l'es,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-ln Fee(If Applicable) $ 2.00 <br /> Total Permit Fee $ <br /> (Permit Fees Continued On Next Page) <br /> 2 <br />