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. <br /> � <br /> ___l <br /> PLUMBING EIYTUR�S BE1NG INSTALLED <br /> FIXTURE BSMT 1 T 2� OTHER FIXTURE BSMT 1sT 2Nn OTI�L'R <br /> TYPE FL FL TYPE I'L FL <br /> Water Closet Floor Drains <br /> - ----- --- --_ <br /> Lavatory Sewer Ejector <br /> Bathtub Laundry Tray � <br /> Shower Washer 1 <br /> Kitchen Sink I Water Heater <br /> Disposal � Water Softener <br /> Dishwasher � Wet Bar <br /> Si(Icocks Miscellaneous <br /> PERMIT FEE CA�,CCJLATIQN(S) <br /> BASED OFF=2002 STATE STATUE" ' <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;excluding the cost of the fixture or appliancc: and <br /> 3. Is improved,installed or rep►aced by the homeowner or licensed plumbing contractor. <br /> Skip next section,if this applies; Cost of Permit $ 15.00 <br /> State Surcharge $ <br /> Mail-In Fee(If Applicable) $._____2_0� <br /> Total Permit Fee $ <br /> (Permit Fees Continued On Next Page) <br /> 2 <br />