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� <br /> PLUMBING FIXTURES BEING INSTALLED I <br /> FIXTURE BSMT 1 2' OTHER FIXTURE BSivIT 1 2 OTHER <br /> TYPE FL FL TYPE FL FL <br /> Water Closet 1 � Floor Drains � <br /> Lavatory I � Sewer Ejector <br /> Bathtub I � Laundry Tray ( <br /> Shower � Washer , � <br /> Kitchen Sink ( Water Heater � <br /> Disposal i Water Softener d <br /> � <br /> Dishwasher i Wet Bar � <br /> Sillcocks � Miscellaneous <br /> I � PERMIT FEE CALCULATION(S) � � j <br /> BASED OFF - 2002 STATE STATUE I <br /> ❑ Yes,this section applies <br /> The replacement of only one Residential fixture or appliance that meets all three of the following <br /> 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 plumbing 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 />