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w <br /> � '� �,�,s. <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 � Laundry Tray ,/ <br /> !' <br /> Shower X Washer � <br /> Kitchen Sink ,�, Water Heater X <br /> Disposal X, Water Softener <br /> Dishwasher X Wet Bar <br /> Sillcocks Miscellaneous <br /> � � <br /> �°������"�° ��;� ���� � �.�, �. " '�=� <br /> ��� ��, }.� 7��� �� � ��" ,� � <br /> .���� �3�.�a::� u,��� <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 reyuire 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 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 />