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�� <br /> i <br /> PLUMBING FIXTURES BEING INSTALLED <br /> FIXTiJRE BSMT 1sT 2vn OTHER FIXTURE BSMT 1sT 2ND OTI-IER <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 /> � . <br /> Disposal Water Softener <br /> Dishwasher Wet Bar <br /> Sillcocks Miscellaneous <br /> �1 <br /> P RNIIT FEE C CULATION(S) <br /> BA ED OFF -2 02 STATE STATUE <br /> [j Yes,this section applies ��� � 1 <br /> � \ <br /> `, <br /> The replacement of only one Resident 1 fi ture or a liance that meets all three o the following <br /> requirements: ; <br /> 1. Does not require modific�`t bn to electrical or gas service. <br /> 2. Has a total cost of$SOO.,flO o�less;excludin�the cost of the fixture or appliance:and <br /> 3. Is improved,installed q�r repl ed by the homeowner or licensed plumbing contractor. <br /> Skip nert section,if this applie • Cost of Permit � 15.00 <br /> � State Surcharge $ .,� ' S-ED <br /> � Mail-In Fee(If Applicable) $ 2.00 <br /> Total Permit Fee $ � � <br /> \ <br /> ,V <br /> � (Permit Fees Continued Oo Next Page) <br /> 2 <br />