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! 1i �y <br /> .. � <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 /> Dishwasher Wet Bar ' <br /> Sillcocks Miscellaneous <br /> UPp�T��JL9 ICTrCl�',� - �nrN� (�) s��res rNc.����� <br /> ��ws �� ►�-��z. ��s�, �--�D��� CZ) �� ����s <br /> ��� �'a o v� �vJ� �N,,� �a r=d2.�P�� <br /> ❑ Yes,this section applies <br /> T'he 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 IVext Page) <br /> � <br />