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4 <br /> PLUMBING FIXTURES BEING INSTALLED <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 /> � <br /> Disposal � Water Softer.er � I <br /> Dishwa$her / Wet Bar <br /> Sillcocks Miscellaneous <br /> PERMIT FEE CALCULATION(S) <br /> BASED OFF - 2002 STA"I�E STATUF, <br /> ❑ Yes,this section applies <br /> The replacement of only one Residential fixture or appliance that meets a►1 three of the following <br /> requirements: <br /> 1. Does not require modification to electrical or gas service. <br /> 2. Has a tetal cost of$500.00 or less; excluding the cost of the fixture or appliance:and <br /> 3. Is i�nproved, ir.stziled or replaced by the homeowner or licensed p!ambine 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 />