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� <br /> ._. <br /> � , l <br /> , �� -PL;U�B�C�F�XX'.'�'U�:�.��13*�..+�"',�'1�ST�iL�.�i�� . .<`, 1.; � <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 Sewer Ejector <br /> Bathtub Laundry Tray <br /> Shower Washer <br /> Kitchen Sink Water Heater <br /> Disposal Water Softener _ / <br /> \/ <br /> Dishwasher � / Wet Bar <br /> v <br /> Sillcocks Miscellaneous <br /> € � , 4 �' a �"�1�� �° �' : <br /> � � : �x� ,-��, '� , r � , - <br /> t- «` �'� '`` � � �`: +x-li. , s 's�- � t�a ?��e�.�k y�-5 a �€�., ,e�.{_-' .�U f;'. <br /> 's � '�-� 3 .'a. £ �° (� s r i °k^��, �4r'�A 72�� Y�s <br /> �« .'r.'°����� >'s�V � ��'�� �;<-4�..�'�`w'' � � ��. .�, .-a � <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;excludin�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 />