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� <br /> " r'�' ;���� r��.�1 <br /> FIXTURE BSMT 1 2 OTHER FIXTURE BSMT 1 2 OTHER <br /> TYPE FL FL TYPE FL FL <br /> Water Closet � Floor Drains � � <br /> t� � L <br /> Lavatory � 1 ' } Sewer Ejector <br /> ` '"1 <br /> Bath�eem t�>� 1 Laundry Tray ' <br /> Shower � ' Washer <br /> Kitchen Sink ' Water Heater ' <br /> Dispasal � 'vVater Softener <br /> Dishwaslier 1 Wet Bar <br /> Sillcocks ; Miscelfaneous <br /> �. <br /> PERMIT�," �' LCUL�� (;�N�S) <br /> ti , � , ,� �. ;{. <br /> $ASED OF�' ;,;,,,,,��;ST.�„T ,�, ATUE <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;excludine the cost of the fixture or appliance: and <br /> 3. Is improved, installed or replaced by the homeowner or license�l 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 />