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10/23/2012 13:12 FAX 9529335049 CULLIGAN MNTKA C�003 <br /> . , z�•;�.4:' �.'�.. ... . <br /> "'=h;lr.�i�,�.t.''.:.r�..rt..!*,1�.':'f��:���:f �"��:"},�r� 1 �y,�^ �%��j!�+�r !p�,i�t .�a:� �:;.,_:,F:�.<<;,;,.�: � <br /> '.i:.. .�}.,ntv.� �}� p•.Hi4'.:...ti�' .i t.. r,):� ,�+! 7-� .�.t',�;.i'.'�i.':,...'�' rA�7+.`]�:.;��.`�"'Si:�� <br /> !�5c.":k�f-:�{.:.,r,'•,I,_w"`:;u_.ui.'` .:{:.>Trc.°�+�,1Y'Il�l�'}����1'`Shc'SG`LT'��li�ilY.K3o��-1',,�.���t"��3J-;;;��.,; _ <br /> FIXTURE BSMT 1 2 OTHER FtXTiJRE BSMT 1 2 OTHER <br /> TYPE FL FL TYPE FL FL <br /> Water Closet Floor Drains <br /> Lavatory Sewer Ejector <br /> I', Bathtub Laundry Tray <br /> Shower Washer <br /> ' Kitchen Sink Water Heater <br /> _ Disposal Water Softener <br /> Dishwasher Wet Bar <br /> Sillcocks Miscellaneous <br /> ��� i✓H y + ��n '�xt,L"�}��"�� Y �l�����i.����H1.�O1.V��,7}� ��4 �;�g�y' �'��,� �����•'�i f� � mar�k } <br /> JI'u :Y ���F �-�j �5 � �' -.f.k ta � -a � �' i iaalt � <br /> ��,��;��; ` , ,��� ��4�''l�t ��, �OQ2 5TA`I'E STATU�' ' �;� r=�„���r; E���"���� <br /> ❑ Yes,tt►is section applies <br /> The replacement of a Residential fixture or ap�liance 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;excludine the cost of the fixture or appliance;and <br /> 3. [s improved,installed or replaced by the homeowner or licensed contractor. <br /> Skip next section,if this applies; Cost of Permit $ 15.00 <br /> State 5urchazge $_ 5.00 <br /> Mail-In Fee(If Applicable) $ 2.00 <br /> Total Permit Fee $ <br /> (Permit Fees Continued On Next Rage) <br /> 2 <br />