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5 �z 21P: CJLTAW`YV,FD,efeltE.&0t*O115110TAXL;-WIV. <br /> "yK p is. <br /> FIXTURE BSMT 1s.1 <br /> . 2ND OTHER FIXTURE BSMT lsl 2ND OTHER <br /> TYPE FL FL TYPE FL FL <br /> Water Closet ` Floor Drains <br /> Lavatory Ii Sewer Ejector <br /> Bathtub Laundry Tray <br /> Shower Washer <br /> Kitchen Sink Water Heater <br /> Disposal Water Softener <br /> Dishwasher Wet Bar <br /> Sillcocks Miscellaneous <br /> ® r • 4 ¢ ,sc a r � <br /> ' ?6-�: + Dazs x .. n}�. + r 'y„l S •. •i <br /> :IF)) ' a r " � ta' <br /> ❑ Yes,this section applies <br /> The replacement of a 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 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 contractor. <br /> Skip next section,if this applies; Cost of Permit $ 15.00 <br /> State Surcharge $ .50 <br /> Mail-In Fee(If Applicable) $ 1.50 <br /> Total Permit Fee $ <br /> (Permit Fees Continued On Next Page) <br /> 2 <br />