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T �� <br /> I <br /> rLUMdING FIx:'TURES sEING INSTALLED <br /> FI�CTURE BSMT 1 2 OTI�R FIXTURE BSMT 1 2 OTT�R <br /> TYPE FL FL TYPE FL FL <br /> Water Closet � Floor Drains f <br /> Lavatory Sewer Ejector <br /> Bathtub Laundry Tray <br /> Shower � �'ash� <br /> Kitchen Sink ' Water Heater � <br /> Disposal � Water Softener <br /> Dishwasher ' W�BaT <br /> Sillcocks � Miscellaneous <br /> PERMIT FEE CALCULATION(S) <br /> BASED OFF -2002 STATE STATUE <br /> ❑ Yes,this section applies <br /> The replacement of only one Residential fixture or apptiance that meets all three of the following <br /> requirements: <br /> 1. Does not require modification to electrical or gas service. <br /> 2. Has a tal cost of$500.00 or less;excludina the cost of the fixture or appliance:and <br /> 3. Is improved,installed or replaced by the homeowner or lic�sed plumbing contractor. <br /> Skip next section,if this applies; Cost of Permit $ I 5.00 <br /> State Surcharge $ 5.00 <br /> Mail-In Fee(If Applicable) $ 2.00 <br /> Total Permit Fee $ <br /> (Permit Feea Continued On Neat Page) <br /> 2 <br />