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r • <br /> PLUMBING FIXTURES BEING INSTALLED 1 <br /> FIXTURE BSMT 1 2 OTHER FIXTURE BSMT 1sT 2ND O.I.IIER <br /> TYPE FL FL TYPE FI_, PL <br /> — ------ -- <br /> Water Closet l � Floor Drains � <br /> ` -- -- ---__ <br /> Lavatory � Sewer Ejector <br /> Bathtub � Laundry'I'ray � . ` <br /> � <br /> Shower Washer <br /> � � � —�-- � - <br /> Kitchen Sink t , Water Heater � <br /> � <br /> Disposal � Water Softener <br /> Dishwasher � Wet Bar 1 <br /> Sillcocks Miscellaneous <br /> PERMIT FEE CALCULATIQN(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;excludin�the cost of the fixture or appliancc: 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 $ 5.00 <br /> Mail-In Fee(If Applicable) $__2.Op <br /> Total Permit Fce $ <br /> (Permit Fees Continued On Next Page) <br /> 2 <br />