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1 � <br /> a <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 l � Sewer Ejector <br /> Bathtub r I Laundry Tray ' <br /> l <br /> Shower 1 � Washer l <br /> Kitchen Sink � Water Heater ( <br /> Disposal � Water Softener <br /> Dishwasher I Wet Bar <br /> Sillcocks 2 Miscellaneous <br /> ❑ Yes,this section applies <br /> T'he replacement of only one Residential fixhue or aQ ln iance 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;excludins 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 />