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� � t ` <br /> T <br /> 1 <br /> :� : <br /> �.r �s-r:,- �xf �.�' e�.^�.f�,�, ',�. �K �� ��: te.�' � ,�,tr.��?'�E' ��S <br /> FIXTURE BSMT 1 2 OTHER FIXTURE BSMT 1 2 OTHER <br /> TYPE FL FL TYPE FL FL <br /> Water Closet (` I Floor Drains <br /> � <br /> Lavatory � � Sewer Ejector <br /> Bathtub ( Laundry Tray <br /> 1 <br /> Shower ' Washer <br /> Kitchen Sink Water Heater <br /> Disposal Water Softener <br /> Dishwasher Wet Bar <br /> Sillcocks Miscellaneous <br /> �� w� <br /> ;� � ;g ��- <br /> �- } <br /> &���° ,� r . <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;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 next section,if this applies; Cost of Permit $ 15.00 <br /> State Surcharge $ 1.00 <br /> Mail-In Fee(If Applicable) $ 2.00 <br /> Total Permit Fee $ <br /> (Permit Fees Continued On Next Page) <br /> 2 <br />