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I <br /> PLUMBING FIXTURES BEING 1NSTALLED <br /> FIXTi_IR.E BSMT 1 ' 2�`D OTHER FIXTURE BSMT 1'T 2 � OTHER <br /> TYPE FL FL TYPE FL FL <br /> Water Closet � Floor Drains � <br /> Lavatory � , � Sewer Ejector <br /> � <br /> Bathtub Laundry T�Q R� <br /> , �� I <br /> Shower � Washer <br /> Kitchen Sink ' Water Heater / <br /> Disposal � Water Softener <br /> Dishwasher � Wet Bar n 1' <br /> r��� <br /> Sillcocks � Miscellaneous <br /> � � <br /> � <br /> PERMIT FEE CALCULATION(S) <br /> BASED OFF - 2002 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; excludinQ 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 />