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r � <br /> �• . <br /> ���'-x _ PL ��. � . � BEING INSTALLED �.��� '; <br /> FIXTURE BSMT 1 2 OTHER FIXTURE BSMT 1 2 OTHER <br /> TYPE FL FL TYPE FL FL <br /> Water Closet / � ��' Floor Drains <br /> l <br /> Lavatory / � !-7 Sewer Ejector <br /> � ` <br /> Bath � Laundry Tray I <br /> Shower � Washer <br /> � <br /> Kitchen Sink � Water Heater / <br /> Disposal � Water Softener <br /> Dishwasher J Wet Bar <br /> I <br /> Sillcocks Miscellaneous <br /> ��.rt-� �l� {�,�fu�.s s,✓ 6'd���`��.a <br /> � PER��fIT 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;excludine 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) $ 1.50 <br /> Total Permit Fee $ <br /> (Permit Fees Continued On Next Page) <br /> 2 <br />