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. , <br /> . `':�P�'��� ���T�'�:.������� ..�,T��T��;�,,�D. ; <br /> F1X�'URE BSMT 1 2 OTHER FIXTURE BSMT 1 2 OTHER i <br /> TYf�E FL FL ,.��(, TYPE FL FL ,��� <br /> Water Closet � Floor Drains <br /> Lavatory � Sewer Ejector <br /> BaKhtub � Laundry Tray <br /> SI�'ower 1 Washer f � <br /> I <br /> K�tchen Sink ' Water Heater <br /> D�isposal Water Softener <br /> � <br /> Dishwasher ' Wet Bar <br /> 5ilicocks Miscellaneous <br /> � I� �����,�� A.�'TC1�(S� <br /> � ��� � � � ��� <br /> ' `� �.����. ;�'���.7E <br /> �.. , . k � � , ' , <br /> .:: ._ .a� . �.aF�... .. .., w ..._. _... . . . .�. <br /> ; ❑ Yes,this section applies <br /> ' The replacement of only one Residential fixture or appliance that meets all three of the follo ing <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 applian e:and <br /> 3. Is improved, installed or replaced by the homeowner or licensed plumbing co tractor. <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 />