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, <br /> � . <br /> , � <br /> W <br /> , _ <br /> w . <br /> '�. ..h.w..` .e x_-,-��. _ '�.�'. 2 .�.....�.. ,� ...�. ..... , a:..�.; ... , r ..:<. , �:r.., i_. u.�."..�x . :..�r.. <br /> FIXTURE BSMT 1 2 OTHER FIXTURE BSMT 1 2 OTHER <br /> TYPE FL FL TYPE FL FL <br /> Water Closet r� Floor Drains <br /> O� <br /> Lavatory ^� Sewer Ejector <br /> G� <br /> Bathtub � Laundry Tray <br /> Shower � Washer <br /> Kitchen Sink � Water Heater <br /> Disposal 1 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 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 />