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11/18/2010 10:24 FA% 9529335049 CULLIGAN ASNTRA f�003 <br /> y�.y ,� ,,.�. <br /> ' e,�. �� ro 5� � !�'4-' i � �� ° �',�1..y��n¢�"` y�Y.. •.��'h�i7�.;i5'�i <br /> i <br /> FIX'f'URE BSMT 1 2 OTHER FIXTURE BSMT 1 2 OTI-IER <br /> 'fYPE FL FL TYPE FL FL <br /> Water Closet Floor Drains <br /> Lavatory Sewer Ejector <br /> g��b Laundry Tray <br /> Shower Washer <br /> Kitc6en Sink Water Heater <br /> Disposal Water Sot�ener <br /> Dishwasher Wet Bar <br /> Sillcocks Miscellaneous <br /> Y �, <br /> T.,M <br /> � Yes,this section applies <br /> The replacement of a Residential fixt�re or appliance that meers all three of the following requirements: <br /> 1. Dogs not require modification to electrical or gas service. <br /> 2. Has a co of$500.00 or less;exc ' the cost of the fixture or appliance:and <br /> 3, is iraproved,instaUed or replaced by the homeowner or licensed contractor. <br /> Skip next section,if this applies; Cost of Permit $ 15.00 <br /> State Surcharge S 5.00 <br /> Mail-tn Fee(lf Appliceble) S 2.00 <br /> Total Permit Fee $ <br /> (Permit Fees Continned On Next Page) <br /> 2 <br />