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Apr 0615 02:34p Legend Services Inc 763-479-6003 p.3 <br /> PLUMBING FIXTURES BEING INSTALLED <br /> FIXTURE BSMT 1 T 2 OTHER FIXTURE BSMT FL FL OTHER <br /> TYPE FL FL TYPE <br /> Water Closet 4 Floor Drains j <br /> Lavatory �! 3 Sewer Ejector <br /> Bathtub Laundry Tray <br /> Shower Washer <br /> Kitchen Sink Water Heater <br /> Disposal ` Water Softener <br /> Dishwasher Wet Bar <br /> Siltcocks ^ Miscellaneous <br /> PERMIT FEE CALCULATIONS) <br /> BASED OFF-2002 STATE STATUE <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;excluding 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 $ 15.0 <br /> State Surcharge $ 5.00 <br /> Mail-In Fee(if Applicable) $ 2.00 <br /> Total Permit Fee S <br /> (Permit Fees Continued On Next Page) <br /> 2 <br />