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� b <br /> 04/09/2013 13:28 FAX 9529335049 CULLIGAN MNTKA C�003 <br /> .,;t,:, � , ' ,,, pL�B`TT1�4��'TU�S`B�II��r i'I�ST�T;��;��D - <br /> FIXTURE BSMT 1 2 OTHER FIXTURE BSMT 1 2 OTHER <br /> TYPE FL FL TYPB FL FL <br /> Water Closet Floor Drains <br /> Lavatory Sewer Ejector f <br /> Bathtub Laundry Tray <br /> Shower Washer <br /> Kitchen Sink Water Heater <br /> Disposal Water Softener � <br /> Dishwasher Wet Bar <br /> Sillcocks Misceilaneous <br /> X � ' y - PERNT�'T.FE�:�AL�U�A.'I'ION(S) � > <br /> ��'�� , ; BASED OI�''F =20Q2 5'1''A'7'E STAIT.TE � ` <br /> Yes,this section applies <br /> 'I'he replacement of a Residential fixture or appliance that meets all three of the following requirements: <br /> 1. Does not require modification to electrical or gas sarvice. <br /> 2. Has a total cost of$500.00 or less;excludine the cost of the fixture or appliance: and <br /> 3. [s improved,installed or replaced by the homeowner or licensed contractor. <br /> Skip next section,if this appiies; Cost of Permit $ 15.00 <br /> 5tate Surchazge $ 5.00 <br /> Mail-In Fee{If Applicablc) $ 2.00 <br /> Total Permit Fee S <br /> (Permit Fees Continued On Next Page) <br /> 2 <br />