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. <br /> ,��� . .r.�... _'r a�-a`�.a �^-^�—'��'..y,:.�.r �y—_ " _ ' _ <br /> ti� '" � e�� �`� � " ���7�rk1'?Fl� l���r� —. ���_—�- <br /> _ - <br /> ; �. . .. — ��� - <br /> FL'�TUR�, BSMT" 1 2 OTH�R FLxTURE BS?vTT 1S 2 orH�� <br /> TYPE FL �T, TY�'�, FT� FL <br /> �WatCr Closet i � � Floar Drains E <br /> t f <br /> Lavatory � � Sewer Ejector <br /> Batht�ib � Laiu�dry'T'ray <br /> � <br /> Shower t i �Washer <br /> � 1 I <br /> Kitchen Sink i Water Heater { <br /> 1 l <br /> Disposal � Water Softener <br /> Dishwast►er i Wet B�r <br /> Sillcoc}�s � Miseellaneous <br /> .��������,���������s� _ � <br /> - _ _ ��:�.�����_ ������������ _ _ _ __ ..� <br /> ❑ "Yes,this section applies <br /> Thi:rc-placeme��t of only one Residential fixhire or appliance that meets all t1ueE of d�e following <br /> requirements: <br /> 1. Does not require rnodifieation to eleca ical or gas srsvic�. <br /> 2. H�s a tot,�l cost of�a500.00 or less;e�eludine th�eost of Ehe fixcure or appliance: and <br /> 3. Is improved,installed or replaeed by rhe homeowner or licensed plumbing contractor. <br /> Skip ncxt Section,if this applies; Cost of Permit $ 15.00 <br /> 5tate Surchar�c; $ 5.00 <br /> Mail-In Fee(If Applicable) $ 2.00 <br /> Total Permit�ee $ <br /> (Permit Fees Cnn�Fuued On Ne�ct page) <br /> 2 <br /> �,Z:a6pd 9L9b6bZZS6��l 98�Z86b�9Z �J1H '8 �JB�Id O�Sd�:wo�.� bS�Ze SZO�-tiT-Nfl!' <br />