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i <br /> � <br /> q ♦ � <br /> ` <br /> PLUMBING FIXTURES BEING INSTALLED <br /> FIXTURE BSMT 1' 2' OTHER FIXTURE BSMT 1 2 OTHER <br /> TYPE FL FL TYPE FL FL <br /> Water Closet Floor Drains ( <br /> l I Z <br /> Lavatory I ' � Sewer Ejector <br /> L <br /> Bathtub � Laundry Tray t <br /> 1 <br /> Shower I Washer � <br /> Kitchen Sink 1 Water Heater I <br /> Disposal I Water Softener <br /> Dishwasher ` Wet Bar <br /> Sillcocks Z Miscellaneous <br /> PERMIT FEE CALCULATION(S) <br /> BASED OFF - 2002 STATE STATUE I <br /> ❑ Yes,this section applies <br /> The replacement of onlv 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 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 Pernut $ 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 />