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♦, <br /> . , . ' � , , <br /> . <br /> n � .M . Y , , - <br /> � � <br /> .. <br /> �, . ,4 x � ��� <br /> � ��,, � x .: . . <br /> ' � :�4 <br /> FIXTURE BSMT 1 2 OTHER FIXTURE BSMT 1 2 OTHER <br /> TYPE FL FL TYPE FL FL <br /> Water Closet � � � Floor Drains � r 7 <br /> E � <br /> Lavatory � � � Sewer Ejector <br /> Bathtub / ' Laundry Tray � <br /> Shower � / � Washer r <br /> Kitchen Sink / I I Water Heater <br /> � <br /> Disposal � l � Water Softener r <br /> ! <br /> Dishwasher / l � Wet Bar � <br /> l <br /> Sillcocks � Miscellaneous <br /> (� �l o�' ��z� —S <br /> a� <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;excludin�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 />