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06/19/2013 21 :43 FAX 7634775629 t�003/007 <br /> . � <br /> ' F1XT�Jy.tE BSMT l 2 O'I��R FIXNRL� $SMT' 1 OTHRR <br /> ' TYPE FL FL �J� TYPE FL FL � <br /> J <br /> ' Weter Close� � Floor Drains <br /> ' I.avatory ? Sewer Bje�ctor <br /> J <br /> ',Bathtub � i„aundry'fl'ay <br /> 'Shovver / Washer <br /> Kitchen 5ia1c � Water Heater <br /> Uisposal � Water SoPtet�� <br /> D�shwashher � Wet Bar <br /> Sillcocks Ivliscellaneous <br /> � <br /> ❑ 'Yes,diis sectioq applies <br /> The replaAcement of only one Rnsid�ial fixtur�ar.anqlians.�that meets all t}uee of the followinig <br /> reyuiremeixts: <br /> 1 i I7Oes ot require modi�ica�tion to electrical or gas service_ <br /> 2.' Has a tal�l cost of$500.00 or 1ess;exclu ' the cost of the fixturc or appliance:and <br /> 3,', Is impraved,instalEed or reptsced by the homenwne�r or lioensed plumbing contractor. <br /> Sicip next section,if this appl ies: C:ost of Permit $ t 5.00 <br /> State Surcharge � 5.00 <br /> � MAiI-Jn Fce(tf Applicable) S^, 2.00 <br /> Tota!Permit�oo s T <br /> (Permrt Fees Contiuued On l�ieatt P�e) <br /> 2 <br />,:,.. _.._ . .. _...—_.._.... <br />