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���:�, � �,��} � ,��^� ��.� x.. ���. .,�-'"�.,.T' .r��,r�.tz +�a �. y �:�x���. <br /> � �,_ &. �.,� +,d' `��, ' �,sa u � .,m��. s Vs <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 Sewer Ejector <br /> Bathtub Laundry Tray <br /> Shower Washer <br /> Kitchen Sink � Water Heater <br /> Disposal � Water Softener <br /> Dishwasher Wet Baz <br /> � <br /> Sillcocks Miscellaneous <br /> � ,� �" �:r �,``�'��,` <br /> �t�{�,��:�, s,''��� �;�*,`� � =� , ��� � ,��' ,,� �'�� �'�� .�a,�' <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 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 $ 5.00 <br /> Mail-In Fee(If Applicable) $ 2.00 <br /> Total Permit Fee $ <br /> (Permit Fees.Continued On Next Page) <br /> 2 <br />