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� <br /> r � <br /> ��:`, S$��'�. .a;'� .�, �,��t�. <br /> FIX'TL7RE BSMT 1 2 OTHER FIXTURE BSMT 1 2 OTHER <br /> TYPE FL FL TYPE FL FL <br /> Water Closet Floor Drains <br /> � <br /> Lavatory % U Sewer Ejector <br /> / <br /> Bathtub / Laundry Tray <br /> � <br /> Shower l Z Washer <br /> Kitchen Sink � � Water Heater <br /> Disposal 1 Water Softener <br /> Dishwasher ; Wet Bar <br /> Sillcocks Miscellaneous <br /> �. � PERMIT FEE CALCULATION(S) <br /> ���a a � , �� � <br /> � BASED OFF — 2002�STATE STATUE �� ��, <br /> ❑ Yes,this section applies <br /> The replacement of a Residential fixture or appliance that meets all three of the following 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 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 />