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$`�". `- �xd: s ''. rr. .'e: r> +"' "9 r 4n s,: <br /> �..�. ,,L �. ro„a xe k,l n L � s.�ax4�`y�°r � � <br /> FIXTURE BSMT 1 s r 2ND OTHER FIXTURE BSMT 1sT <br /> 2ND OTHER <br /> TYPE FL FL TYPE FL FL <br /> Water Closet / 3 Floor Drains <br /> Lavatory I / c Sewer Ejector <br /> Bathtub Z Laundry Tray <br /> Shower Washer <br /> Kitchen Sink z Water Heater <br /> Disposal Z Water Softener <br /> Dishwasher Z Wet Bar <br /> Sillcocks .L 4 Miscellaneous <br /> s ,+' <br /> y..� i t f <br /> 4 <br /> 5. -ar £�' 3x s-A.,.s S.a� _u, <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 />