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02/18/2013 14:13 FAX 9529335049 CULLIGAN MNTKA IJ003 <br /> "datR;;SaL:. -e� .b;yM 1 19: 0t104-n G0e0WI.aw)•.:fid'+%'9rs <br /> FIXTURE BS lST 2ND OTHER FIXTURE BSMT 1ST 2ND OTHER <br /> TYPE L FL TYPE FL FL <br /> Water Closet Floor Drains <br /> Lavatory r Sewer Ejector <br /> Bathtub I Laundry Tray <br /> Shower I Washer <br /> Kitchen Sink Water Heater <br /> Disposiil ..__ _ _ _ Water Softener r, <br /> Dishwasher Wet Bar <br /> Sillcocks Miscellaneous <br /> L <br /> r � fAti 7.'.�ry'.7 it'''4►ih�': iT �. t ilii' f <br /> t <br /> �"�1i...�� �C .: )t �Z T a <br /> rc .r,T,i,r,.�rarit `go - 1� ,r'•3, ,t- {t.' y "s�� ,��d<<�., �. N NA t� rily+ <br /> ks 'ii�if��J �l[�'���t�x���1Y.��:,..�.�.�.,.�",'.rw`.iwr,.f+./n)Rv,,.l'ri�.I.u:L„�mt� ���� �" h� t�ti�.,�a;�. <br /> Yes,-this section applies <br /> The reptaccni m-o'Fa Residential fixture or appliance that meets all three of the following requirements: <br /> 1. Does not require modification to electrical or gas service. <br /> 2. Has al otalcost 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 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 /> i; , ;gip; 2 <br />