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� <br /> ,� -, � . � � ti.. .. �.. . � <br /> �. �. k.� « .. <br /> .., . <br /> '�. �°� ' , . , a . <br /> . . :� 0.3.��.a-. . 4'.... ° . _ 1vA <br /> . <br /> _ . .. . . „.._, i,t c� .'£�+�z .r.... .a.. :t .-.. - � � "' <br /> FIXTURE BSMT 1 2 OTHER FIXTURE BSMT 1 2 OTHER <br /> TYPE FL FL TYPE FL FL <br /> Water Closet Floor Drains <br /> Lavatory Sewer Ejector <br /> Bathtub Laundry Tray <br /> Shower Washer <br /> Kitchen Sink Water Heater <br /> Disposal Water Softener / <br /> v <br /> Dishwasher Wet Bar <br /> Sillcocks Miscellaneous <br /> ❑ Yes,this section applies • <br /> The replacement of only one Residential fixture or appliance that me�ts all.three of the following <br /> requirements: � <br /> 1. I?oes"not require modification to electrical or gas service. <br /> 2. Has a total cost of$500.00 or less;excludine 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 PermitFee , °�$ <br /> ,. <br /> (Permit Fees Continued On Next Page) ` <br /> 2 <br />