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PLUMB�NG FI�TURE��BEIl�+TG INSTALLED <br /> FIXT'LTRE BSMT 1 2 OTHER FIXTURE BSMT 1 2 OTI�R <br /> TYPE FL FL TYPE FL FL <br /> Water Closet � Floor Drains � <br /> Lavatory � � Sewer Ejector � <br /> Bathtub I Laundry Tray _ <br /> Shower � Washer . � <br /> Kitchen Sink � Water Heater � <br /> Disposal Water Softener <br /> Dishwasher Wet Bar ' <br /> Sillcocks f�,j Miscellaneous � <br /> � <br /> �E�r��c�,cvl;��ort�s� <br /> BASED fJFF-.20�2 STATE�"fiATCJE <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;excludinQ 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 Surcharge $ 5.00 <br /> Mail-In Fee(If Applicable) $ 2.00 <br /> Total Permit Fee $ <br /> (Permit Fees Continued On Neat Page) <br /> 2 <br />