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� <br /> "r. <br /> c <br /> F. <br /> � , <br /> � 1. <br /> � �. A... <br /> � 3 gA� g � . ��9 i,.' § �"�'�, ��„' ' .. <br /> $ <br /> FIXTURE BSMT 1 2 OTHER FIXTURE BSMT 1 2 OTHER <br /> TYPE FL FL TYPE FL FL <br /> Water Closet � Floor Drains � p <br /> Q�A.:� <br /> Lavatory � � Sewer Ejector <br /> Bathroom � � ^ Laundry Tray <br /> / —� 1 <br /> Shower Washer <br /> � � <br /> Kitchen Sink Water Heater <br /> � <br /> Disposal 1 Water Softener <br /> Dishwasher ' Wet Bar I <br /> Sillcocks � Miscellaneous <br /> PCRMIT FEE CALCULATION(S) � <br /> 13ASED OFF - 2002 STATE STATUE <br /> ❑ Yes,this section applies <br /> The replacement of a Residential fixture or appliance that meets all three of the following requirements: <br /> 1. Does not require modification to electrical or gas service. <br /> 2. Has a total cost of$500.00 or less;excludin�the cost of the fixture or appliance: and <br /> 3. Is improved, installed or replaced by the homeowner or licensed contrzctor. <br /> Skip next section, if this applies; Cost of Permit $ 15.00 <br /> State Surcharge $ .50 <br /> Mail-In Fee(If Applicable) $ 1.50 <br /> Total Permit Fee $ <br /> (Permit Fees Continued On Next Page) <br /> 2 <br />