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`� <br /> . y, � <br /> , .� - � � � � �� �. <br /> s«'` r , M�'�C�,.�:M 'a.",rrw,`�y�al��,- .,� .�' '�,y�.w� E� '�,> .:;�' -�� ' <br /> . <br /> FIXTURE BSMT 1 2 OTHER FIXTURE BSMT 1 2 OTHER <br /> TYPE FL FL TYPE FL FL <br /> Water Closet � � � Floor Drains I <br /> Lavatory � � Sewer Ejector � <br /> Bathtub Laundry Tray � <br /> Shower Washer <br /> Kitchen Sink Water Heater I <br /> Disposal Water Softener <br /> Dishwasher � Wet Bar � <br /> Sillcocks � Miscellaneous <br /> � '� °� � � � <br /> � � � <br /> �a *�. ' <br /> ..�-�r ,� � <br /> ❑ Yes,this section applies <br /> The 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 $ 1.00 <br /> Mail-In Fee(If Applicable) $ 2.00 <br /> Total Permit Fee $ <br /> (Permit Fees Continued On Next Page) <br /> 2 <br />