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� • �_ � • \ � <br /> r e <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 /> / <br /> Kitchen Sink / Water Heater <br /> / <br /> Disposal Water Softener <br /> Dishwasher � Wet Bar <br /> Sillcocks Miscellaneous <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;excludine the cost of the fixture or appliance: and <br /> 3. Is improved,installed or replaced by the homeowner or licensed pluxnbing 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 Negt Page) <br /> 2 <br />