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� <br /> � <br /> � <br /> �, (� <br /> y :���Y��,�' ,;�x�`�� r �lr :'�'� .�.��� ';1i�� ���f ,t �,. �, ` �.s,ts� '` .� �'� "�:� ,�°'�iSl�r; <br /> - �.5 .L-+. �:. ..�e':o��.6i�;A''"�Ji:....P �4�"�A�u.al <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 k Laundry Tray <br /> Shower Washer <br /> Kitchen Sink Water Heater <br /> Disposal Water Softener <br /> Dishwasher Wet Bar <br /> Sillcocks Miscellaneous <br /> �e� � ��a� w.5��rt �5 r��'�'��v�����J����r./'1..t 6 ��1 1 �. �F7�} r r .� zrv ,� �p,�i �-�� � Y����. <br /> �.���"e'f����.�it '����� ,,:.":",an�'J'�"r���'� a ,'��x��+-+�.V�;*'� , ���y�.',�' .���� } �;., � h; � �` <br /> ❑ Yes,this secrion applies <br /> The replacement of only one Residential fixture or anpliance 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 secrion,if this applies; Cost of Permit $ 15.00 <br /> State Surchazge $ 5.00 <br /> Mail-In Fee(If Applicable) $ 2.00 <br /> Total Permit Fee $ <br /> (Permit Fees Continued On Nezt Page) <br /> 2 <br />