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1 <br /> � ` <br /> I, <br /> PL�B�C�F�tTRE�,:�� � �'.T�ST�iL�.��� {�° `� <br /> FIXTURE BSMT 1 2 OTHER FIXTURE BSMT 1 2 OTHER <br /> TYPE FL FL TYPE FL FL <br /> Water Closet , � Floor Drains � <br /> Lavatory I � Sewer Ejector <br /> Bathtub � Laundry Tray , <br /> Shower � Washer � <br /> Kitchen Sink 1 Water Heater ` <br /> Disposal � Water Softener <br /> Dishwasher 1 Wet Baz <br /> ! <br /> Sillcocks � Miscellaneous <br /> . Y t ft�'Y 3 . �.. : .: '?"'F 4 X- �t�. f :�..§�� ...� �z p. , <br /> � Fye S ! b '�J .' i Ti <br /> ° k �? °'t,"ts3 ��:-� v Z - 'y' x"y`"� y tr�; ��[ s�i:+fC S +.�;��' a��• <br /> ���,, x" .w� � � � �a'"v.��,.-,�v�'���,- t 'v <br /> ❑ Yes,this section applies <br /> T'he 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;excludine 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 />