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09/29/2015 TUE 8: 22 FAx 763 473 8565 Sdbre Hedting b Ai.r Cond �043/007 <br /> . , <br /> FI3�TURE BSM1' t 2 OTT�It F+T�CTU'R� BSMT 1 2 OTHETt <br /> 'T"Yr� FL FL TYPE �'I. T�L <br /> Water C�oset � � � Ploor Draina <br /> � � <br /> Lavatory � 1 � Sewer�jecwr <br /> Aathtub � Lsundry Tray <br /> Shawer I � Wnshar , I <br /> � <br /> Kitchen$ink I Water Heater � <br /> Disposal � Water Softener <br /> Dishwasher ` Wet�ar � ' <br /> Sillcocics � 1ltisoollaneous <br /> ❑ Yes,this section applies <br />� The rcplacernant af only one Residontial�xture or appliancc thst macts all three of the following <br /> reyuirements: <br /> 1. �requiro modif'ication to alectrical or gas sarvics. <br /> 2. Has a�g�of�SD0,00 or less;excludina the cost of the�i�rture or applience:and <br /> 7. Is improved,installed o�repaaced by the bomeowner or licensed plumbing contractor. <br /> Skip next aection,if this applias; Coat of Permit 5,,,�, 15.00 <br /> State 5urcharge S 5•00 <br /> Mail-?n Fea(If Applicablo) � 2.00 <br /> Totnl Permit Boo S <br /> (Pe��rnit Fees Contiaued pn Ne:tP�ge) <br />� <br /> I 2 <br /> i <br />