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♦ , � \ <br /> .. y ,.' � . d . M .� . <br /> �. <br /> . 9 � h ' <br /> :.�' '.'R"�� .1� M°+�:}i,'.�i S,r. --"'t.' �^a�Y4A� �1d x <br /> FIXTURE BSMT 1 2 OTHER FIXTURE BSMT 1 2 OTHER <br /> TYPE FL FL TYPE FL FL <br /> Water Closet Floor Drains <br /> Lavatory Sewer Ejector <br /> Bathtub iI Laundry Tray <br /> l� <br /> Shower �f Washer <br /> �_ <br /> Kitchen Sink � Water Heater <br /> Disposal iJ Water Softener <br /> L <br /> Dishwasher � Wet Bar <br /> Sillcocks Miscellaneous <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 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 />