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♦. <br /> . <br /> , y <br /> � : �,.� ,. u��,,.��� � <br /> FIXTURE BSMT 1 2 OTHER FIXTURE BSMT 1 2 OTHER <br /> TYPE FL FL TYPE FL FL <br /> Water Closet r Floor Drains <br /> r <br /> Lavatory ` Sewer Ejector <br /> / <br /> Bathtub Laundry Tray <br /> Shower � Washer <br /> Kitchen Sink Water Heater <br /> Disposal Water Softener <br /> Dishwasher Wet Bar <br /> Sillcocks Miscellaneous <br /> ��. < ���, <br /> ❑ Yes,this section applies <br /> T'he replacement of only one Residential fixture or appliance that meets all three of the following <br /> requirements: <br /> 1. Does not require modificarion 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 plumbing contractor. <br /> Skip next section,if this applies; Cost of Pernut $ 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 />