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� <br /> , . <br /> r <br /> 5 � <br /> a.'•��'-y �-_. <br /> FtXTURE BSMT 1 2 OTHER FIXTURE BSMT 1 2 OTHER <br /> TYPE FL FL TYPE FL FL <br /> Water Closet Floor Drains <br /> -- .� �,� � <br /> Lavatory '7 -j SewerEjector <br /> 1_, <br /> Bathr-0e►x�f�,t� � ` � Laundry Tray � _ <br /> I <br /> Shower � � � Washer <br /> Kitchen Sink Water Heater � <br /> Disposai Water Softener <br /> Dishwasher �; Wet Bar <br /> Sillcocks Miscellaneous <br /> �-, <br /> ��;, PERM['I'I�EE CALCULATION(S) t' ` ' <br /> � �BASED OFF - 2002 STATE STATUE ���., � � :v � ��������� ' <br /> ❑ Yes,this section applies <br /> The replacement of a Residential fixture or appliance that meets all three of the folfowing requirements: <br /> 1. Does not require modification to electrical or gas service. <br /> 2. Has a tota(cost of$500.00 or less;excludin�the cost of the fixture or appliance: and <br /> 3. Is imp;oved, installed or;ep�ac�::by ti�e iiomeown�r o;li�ensed c�ntracior. <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 />