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' �:�,� .��` ��,; � <br /> FIXTURE BSMT 1 2 OTHER FIXTURE BSMT 1 2 OTHER <br /> TYPE FL FL TYPE FL FL <br /> Water Closet � � 2 Floor Drains � <br /> Lavatory 1 1 4 Sewer Ejector <br /> Bathtub � Laundry Tray 1 <br /> Shower � Washer <br /> Kitchen Sink � Water Heater � <br /> Disposal � Water Softener <br /> Dishwasher � Wet Bar <br /> Sillcocks 2 Miscellaneous <br /> $�,Tu°'�i��'�' .`����'''��!� f�,� ���� ,: <br /> ��l����'"'J�'h�������i, <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;excludinQ the cost of the fixture or appliance:and <br /> 3. Is improved,installed or replaced by the homeowner or licensed plumbing contractor. <br /> Skip neact 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 />