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• � � � � <br /> PL�JMBIN.�'".�-FIXTC:TR.�'.S BEIN+G Il'��T,�T,L�I� <br /> FIXT`URE BSMT 1 2 OTI�R FIXTURE BSMT 1 2 OTF�R <br /> TYPE FL FL ��-J TYPE FL FL <br /> Water Closet ,^ Floor Drains <br /> �1 <br /> Lavatory � Sewer Ejector <br /> Bathtub i Laundry Tray <br /> Shower Washer <br /> ( <br /> Kitchen Sink � Water Heater <br /> Disposal Water Softener <br /> Dishwasher � Wet Bar <br /> S illcocks Miscellaneous <br /> PE��`F�� C�1I:.C�TLA'i'TC1N(5) <br /> BA�ED OFF -2D02 STATE STATIJ� <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 n require mod�cation to elecizical 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 secrion,if this applies; Cost of Permit $ 15.00 <br /> State Surcharge $ 5.00 <br /> Mail-In Fee(If Applicable) $ 2A0 <br /> Total Permit Fee S <br /> (Permit Fees Continued On Neat Page) <br /> 2 <br /> � <br />