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l ' <br /> FIXTURE BSMT 1 2 OTHER FIXTURE BSMT 1 2 OTHER <br /> TYPE FL FL TYPE FL FL <br /> Water Closet 1 t y 1 .l Floor Drains <br /> � <br /> Lavatory I 1 F ' r Sewer Ejector <br /> Bathraom� ,� _ Laundry Tray <br /> l � � ' � <br /> Shower Washer i ' <br /> Kitchen Sink , Water Heater � <br /> Disp�sal � Water Soitener <br /> Dishwasher Wet Bar <br /> � � T' <br /> Sillcocks Miscellaneous r <br /> \�T`�.. — �, `��f7c�Ylk��<U+� I��lt. � � \1v� ��.:ititl�� i:.����..1.A�;.A��1��� �1�'1�. <br /> �`�'� 'ATZON(S) <br /> « <br /> ���q �, , <br /> „ ;, ,,���r� 'F.T�;STATU� <br /> ❑ Yes,this section appfies <br /> The 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 service. <br /> 2. Has a total cost of$500.00 or less;excludine the cost of the fixture or appliance: and <br /> 3. Is in�;;ro���d,insi;.:led cr rzplaccd�y t��e;�ismeowr,er or;icensed coniractor. <br /> Skip next section, if this applies; Cost of Permit $ ]5.00 <br /> State Surcharge $ .50 <br /> Mail-In Fee(If Applicable) $ 1.50 <br /> Total Permit Fee $ <br /> (Permit Fees Continued On Next Page) <br /> 2 <br />