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T e `..PLUMBING FIXTURES BEING INSTALLED <br /> FIXTURE BSMT ls' 2ND OTHER FIXTURE BSMT 1s' 2ND OTHER <br /> TYPE FL FL TYPE FL FL <br /> • Water Closetr Floor Drains <br /> / Z Z <br /> Lavatory / S Sewer Ejector <br /> Bathtub Laundry Tray <br /> Shower / / Washer <br /> Kitchen Sink Water Heater <br /> Disposal Water Softener / <br /> Dishwasher Z Wet Bar / <br /> Sillcocks Z Miscellaneous A <br /> CAZ1-AC DZ,niu �Y���in <br /> BERM <br /> `��,� _ ALCULATION( <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 $ 15.00 <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 />