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PLUMBING FIXTURES BEING INSTALLED <br /> FIXTURE BSMT 1 2 OTHER FIXTtJRE BSMT 1 2 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 Water Heater <br /> Disposal Water SoRener <br /> Dishwasher Wet Bar <br /> Sillcocks Miscellaneous � <br /> PERNIIT FEE CALCULATION(S) <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;excluding 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 $ .50 <br /> Mail-In Fee(If Applicable) S 2.00 <br /> Total Permit Fee $ <br /> (Permit Fees Continued On Neat Page) <br /> 2 <br />