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R';:��y�i� � <br /> �g,�'i .,y� �n.. <br /> FIXTURE BSMT 1 2 OTHER FIXTURE BSMT 1 2 OTHER <br /> TYPE FL FL TYPE <br /> FL FL <br /> Water Closet .Z Floor Drains <br /> Lavatory u Sewer Ejector <br /> 1 <br /> Bathroom I Laundry Tray <br /> Shower � Washer <br /> Kitchen Sink Water Heater <br /> DispeS�l Water Sofiener <br /> Dishwasher Wet Bar <br /> Sillcocks Miscellaneous <br /> � � •.'�Y ' ` ii���; t '�,q-r��-=�- <br /> �'xia � ti'qri ar i6�� � �t �,� d ' "# �w r " <br /> �,:f, t:l t�` F;� r t��� t. +�.� �y��,t �v�. �a �+ N: ! <br /> �'' ._ �F '��� �.T VT'` r t t .�� �i' N ���t� 4,�`, � <br /> A' <br /> ❑ Yes,this section applies <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 improved,installed or replaced by the h�:r►eo�A�r.e:or;icens�d coniractor. <br /> Skip next section,if this applies; Cost of Permit $ 15.00 <br /> State Surcharge $ .SO <br /> Mail-In Fee(If Applicable) $ 1.50 <br /> Total Permit Fee $ <br /> (Permit Fees Continued On Next Page) <br /> 2 <br />