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PLUMBING FIXTURES BElNG INSTALLED <br /> FIXTLJRE BSMT 1 S 2 OTHER FIXTURE BSMT l S 2i''D OT'I�R <br /> TYPE FL FL TYPE FL FL <br /> Water Closet I � Floor Drains � <br /> Lavatory � � Sewer Ejector <br /> Bathtub '�( I Laundry Tray 1 <br /> � <br /> Shower ^ Washer <br /> � r <br /> Kitchen Sink 1 Water Heater <br /> Disposal ` Water Softener <br /> Dishwasher � � Wet Bar I <br /> Sillcocks r�,� Miscellaneous � <br /> J <br /> PERMIT FEE�'CALCULATION(S) <br /> BASED OFF - 2002 STATE STATUE <br /> ❑ Yes,this section applies <br /> The replacement of only one Residentiai fixture or appliance that meets all three of the foliowing <br /> requirements: <br /> l. 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 $ 5.00 <br /> Mail-In Fee(If Applicable) $ 2.00 <br /> Total Permit Fee $ <br /> (Permit Fees Continued On Next Page) <br /> 2 <br />