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°( FI;UMBING FIXTURES BEING iNSTALLED <br /> FIXTURF„ BSIvIT 1' 2' OTHFR FIXTURE BS1�4T 1' 2 O'i'HGR <br /> TYPE FL FL Tl�'PE Fi_, €�L <br /> 1�Vater Closet Floor[7rains <br /> Lavatory ' Sewer Ejeeror <br /> Bathtub ' Laundry Tray <br /> Shawer W'asher <br /> KitcE�en Sink � 4VaCer f-leater <br /> Disposal Water Sat�ener 1 <br /> Dish�vashcr Wet i3ar <br /> Sillcocks Miscellancaus <br /> '� � � �PERMI"I'PEB�ALCI�LATION(S) �` � � <br /> I BASED OFF-2002 STATE STATUE <br /> � Yes,this scction applies <br /> ,� ' <br /> The rcpincci��cnt ofonly one Residenti�l fixture or„a��liance ihat meets all tt�r�e ofthe t'otlowing <br /> requirernc:nts <br /> 1. Daes not requirc madification to electrical or g7s senlice. <br /> 2. Has a total cost of$500.00 ar less;e�cludinc;thc cost ofthe fixturt or appliance:and �6'�-� <br /> 3. fs improved, installed or replaced by the homeo�vner or licensed plumbing cnntractor. ('�-� �i'"� <br /> Skip next section,if this applies; Cost of Permit �y .��� <br /> State Surchar�e $ .0(1 <br /> Maif-In Fer(IfApplicable} $ ?.QO <br /> `Cota[Permit Fee S �e�� <br /> (Permit Fees Continued On Next Page) <br /> 2 <br />