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12�j3Q/20,13 15:10 FAX 9529335049 CULLIGAN MNTKA f�003 <br /> I <br /> >` P� U�'�NG�I.�TU�ES'BE�TG,Ti�fST�►.L;�;�A� <br /> FIXTURE BSMT 1 2 OTHER FIXTURE BSMT 1 2 OTHER <br /> 'I'YPE FL FL TYPE FL RL <br /> Water Closet Floor Drains <br /> Lavatory Sewer Ejector <br /> Bathtub Laundry Tray <br /> Shower Washer <br /> Kitchen Sink Water Heater <br /> Disposal Water 5oftener <br /> � <br /> Dishwasher Wet Bar <br /> Sillcocks i�liscellaneous <br /> �`��' ` � F'�RNflT FE�CA�CUT:A'�'ION(S) ` , � r �u� fi��, �,P <br /> . , <br /> ,�= _ BASED O��-2�0`Z,�Ti�TE�TA7'i.l� ���� r,� ;�'r..:-�;��:���,+'';�,�; <br /> �f Yes,this section applics <br /> �� <br /> The reptacement of a Residential f xture or appliance,that meets al!three of the following requirements: <br /> 1, Does not require modification to elecirical or gas service. <br /> 2. Has a total cost of$500.00 or less;excludinQ the cost of thc fixture or appliance:and <br /> 3. Is improved, installed or replaced by the homeowner or licensed 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 />