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� -/ <br /> � � �t ` a� 4' � <br /> '��' «. ��r�jz���� .>��� `�t?"��1���� .:�#��#a���' a�ar w;:��r r��`�rF.����`r. <br /> FIXTURE BSMT 1 2 OTHER FIXTURE BSMT 1 2 OTHER <br /> TYPE FL FL TYPE FL FL <br /> Water Closet � � � Floor Drains U <br /> / <br /> Lavatory ! i S Sewer Ejector <br /> ! <br /> Bathtub � Laundry Tray 1 - > <br /> Shower l - � Washer � � <br /> Kitchen Sink � Water Heater <br /> Disposal � / Water Softener <br /> l <br /> Dishwasher / / Wet Bar � � <br /> ! <br /> Sillcocks G/ Miscellaneous <br /> ( <br /> � '�`�;�` `,� � 4 � a��`. T �,' �,� ��� <br /> � � � �, r� '�� �•. �,� � <br /> 5:.��, � .e., :5� .k § �.ti :A .z�..�u',.F+� �'�e.:�"„r�4�.�,�: <br /> ❑ Yes,this section applies <br /> The replacement of a Residential fixture or appliance that meets all three of the following 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 appliance: and <br /> 3. Is improved,installed or replaced by the homeowner or licensed contractor. <br /> Skip next section,if this applies; Cost of Permit $ 15.00 <br /> State Surcharge $ .50 <br /> Mail-In Fee(If Applicable) $ 1.50 <br /> Total Permit Fee $ <br /> (Permit Fees Continued On Next Page) <br /> 2 <br />