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t , . <br /> � � .: � �,, ����� .,� `��� PL�C:�B��i; ..� ��� ���� �°S BEIN���f'�T��,�7����� � ��:F,��«� <br /> FIXTURE BSMT 1 2 OTHER FIXTURE BSMT 1' 2 OTHER <br /> TYPE FL FL TYPE FL FL <br /> Water Closet � Floor Drains <br /> Lavatory � Sewer Ejector <br /> �- / Laundry Tray <br /> 8�t� T�r3 � <br /> Shower � Washer <br /> Kitchen Sink Water Heater <br /> Disposal Water Softener <br /> Dishwasher Wet Bar <br /> Sillcocks Miscellaneous <br /> �� PERMIT �EE CALCULATION(S) � � <br /> BASED nFF - 2002 S'T'ATE STATUE <br /> ❑ Yes,this section applies <br /> The replacement of a Residential fixture or appliance that meets all three of the following requirements: <br /> ]. 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 $ l 5.00 <br /> State Surcharge $ .50 <br /> Mail-In Fee(If Applicabie) $ 1.50 <br /> Total Permit Fee $ <br /> (Permit Fees Continued On Next Page) <br /> 2 <br />