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t <br /> ���,x "� �v��-:t <br /> FIXTURE BSMT 1 2 OT'I�R FIXTURE BSMT 1 2 OTI�R <br /> TYPE FL FL TYPE FL FL <br /> Water Closet 1 � Floor Drains I <br /> Lavatory ( � Sewer Ejector <br /> Bathtub � Laundry Tray I <br /> Shower 1 � Washer <br /> Kitchen Sink Water Heater <br /> � <br /> Disposal Water Softener <br /> Dishwasher f Wet Bar <br /> 1 <br /> Sillcocks 2 Miscellaneous <br /> �; � ; <br /> � �im��. <br /> �-� �',��„��'�����, <br /> �Y �� <br /> , <br /> rf ��;:�=�' � <br /> ❑ Yes,this section applies <br /> The replacement of only one Residential fixture or apnliance 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 ne�ct 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 />