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, , <br /> � . 4 <br /> FIXTURE BSMT 1 2 OTI�R FIXTURE BSMT 1 2 OTI�R <br /> TYPE FL FL TYPE FL FL <br /> Water Closet Floor Drains <br /> Lavatory Sewer Ejector <br /> Bathtub Laundry Tray <br /> Shower Washer <br /> Kitchen Sink Water Heater <br /> Disposal Water Softener � <br /> Dishwasher Wet Bar <br /> Sillcocks Miscellaneous <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;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 ne�ct section,if this applies; Cost of Permit $ 15.00 <br /> State Surchazge $ 5.00 <br /> Mail-In Fee(If Applicable) $ z'ti:99' <br /> Total Permit Fee $ O� <br /> (Permit Fees Continued On Next Page) <br /> 2 <br />