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� <br /> PLUMBING FIXTURES BEING INSTALLED <br /> FIXTURE BSM'f l�� 2�D OTIiER FIXT�IRE BSM"I' 1'T 2�D OTIII?2 <br /> TYPE FL FL TYPE FL �L <br /> Water Closet � Floor Drains <br /> Lavatory Sewer Ejector <br /> Bathtub Laundry Tray <br /> Shower Washcr <br /> Kitchcn Sink Water Heater <br /> Disposal Water Softener <br /> Dishwasher Wet F3ar <br /> Sillcocks Miscellaneous <br /> PERMIT FEE CALCULATION(S) <br /> BASED OFF -2002 STATE STATUE <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;excludin�the cost of the fixture or appliancc: 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 $ 1.00 <br /> Mail-In Fee(If Applicable) $_ 2.00 <br /> Total Permit Fee $ <br /> (Permit Fces Continued On Next Pa�e) <br /> 2 <br />