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� <br /> . _ � <br /> . <br /> 4P f'�'g��:�` hA �'�'. 2 �' �Y G�'4-.�4� &�$e a^'. <br /> �...n: <br /> � ,a„-d. �a,t��<s�'S�� <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 L �J Sewer Ejector <br /> � <br /> Bathtub ' � Laundry Tray I <br /> Shower I Washer � � <br /> Kitchen Sink � Water Heater � <br /> Disposal I Water Softener <br /> Dishwasher t Wet Bar <br /> l <br /> Sillcocks Miscellaneous <br /> � � �� � ��� `�z� � � _� �� <br /> .� y �4 �k'," 3 �� �,�° <br /> ��`�;E� + '� �� v � �`�4 �t� `��`� `�� x � <br /> �`� � �. "Fr� �r���, � : �„ � �..s�`,�, L .. �wb��,.�s �'Y ���yr�,�h.� � <br /> ,�y �'� �- -�°c ,��: E .�f,PE r€ �,x,=-.� :�. 'cv�!d <br /> ❑ Yes,this secrion 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 plumbing contractor. <br /> Skip next section,if this applies; Cost of Permit $ 15.00 <br /> State Surcharge $ 1.00 <br /> � Mail-In Fee(If Applicable) $ 2.00 <br /> Total Permit Fee $ <br /> (Permit Fees Continued On Next Page) <br /> 2 <br />