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PLUMBING FIXTLTRES BEING INSTALLED <br /> FIX"I'Z.JRE BSMT 1 2 OTHER FIXTiJRE BSMT 1 2 OTFIEK <br /> TYPE FL FL TYF'E FL FI, <br /> Water Closet � I � Floor Drains I � <br /> Lavatory � ( ,` Sewer Ejector <br /> 'T <br /> Bathtub � Laundry Tray ` <br /> I <br /> Shower � � Washer 1 <br /> Kitchen Sink I Water Heater i <br /> Disposal ' Water Softener <br /> Dishwasher i Wet Bar ' <br /> Sillcoc;ks � Miscellaneous <br /> PERMIT FEE CALCULATION(S) <br /> BASED OFF- ?00? STATE STATUE <br /> ❑ Yes,this section applies <br /> The replacement of only 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;excludina 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 Permit $ 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 />