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�� ��� £Ea.��� � ,,. .. ,., . ._,. <br /> � � -� ; <br /> FIXTURE BSMT ls 2N�� OTHER FIXTURE BSMT 1sT 2"n OTHER <br /> TYPE FL FL TYPE FL FL <br /> Water Closet � I 3 Floor Drains � <br /> Lavatory � ` � Sewer Ejector � <br /> 1 <br /> Bathtub � � Laundry Tray � <br /> Shower ( Washer i <br /> I <br /> Kitchen Sink t Water Heater I <br /> 1 <br /> Disposal Water Softener <br /> Dishwasher � Wet Bar <br /> Sillcocks •1 Miscellaneous <br /> b� <br /> � � s y .�:. ..,,.. _:. - <br /> : /h £ �$P � � :.......,.. . ._.. <br /> ... �...; � �� \ '� �\. <br /> i .:- � <br /> ��mh'nt3 3 :» � �`�`������ /- a..,__ :� • `� .. '- �at. . � <br /> '._.. ... ' � ;�n;i�.... ..: .. '� �.�.�,. :� :, ''-�,,, � �' <br /> � <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[otal 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 $ 5.00 <br /> Mail-In Fee(If Applicable) $ 2.00 <br /> Total Permit Fee $ <br /> (Permit Fees Continued On Next Page) <br /> 2 <br />