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� <br /> • ' <br /> ' PLUMBING FTXTURES BEING INSTALLED' <br /> FIXTURE BSMT 1 2' OTHER FIXTURE BSMT 1 2` OTHER <br /> TYPE FL FL TYPE FL FL <br /> Water Closet / Flo or Drains <br /> l <br /> Lavatory � Sewer Ejector <br /> Bathtub Laundry Tray <br /> Shower Washer <br /> K�chen Sink � Water Heater <br /> �� <br /> Disposal � / Water Softener <br /> ( <br /> Dishwasher Wet Bar � <br /> Sillcocks Miscellaneous <br /> F.�r��� �� �,,� � �,���- �-'� �Y��S .�-�� <br /> ' � �� PERMIT FEE CALCULATION(S) '�� <br /> BASED QFF -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;excludine 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 />