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i <br /> . - � <br /> PLUMBING FIXTURES BElNG INSTALLED <br /> FIXTURE BSMT 1 2' OTHER FIXTURE BSMT 1` 2 OTHER <br /> TYPE PL FL TYP� FL FL <br /> Water Closet I � Floor Drains <br /> � <br /> Lavatory � Se��-er Ejector <br /> � <br /> Bathtub i � Laundiy Tray <br /> I <br /> Shower Washer , <br /> 0 <br /> ICitcheii Sink � Water Heater <br /> Disposal / Water Softener <br /> Dishwasher Wet Bar I <br /> Sillcocks � Miscellaneous <br /> . � <br /> � / <br /> / <br /> PERIVIIT FEE CALCULATION(S) <br /> BASED OFF - 2002 STATE STATUE <br /> ❑ Yes,this section applies <br /> The replacement of a Residential fixhu•e or a��liance that meets all tluee of the following requireinents: <br /> 1. Does iiot require modification to elech�ical or gas service. <br /> 2. Has a total cost of$500.00 or less;excludiug the cost of tl�e fixttu�e or applianee: aild <br /> 3. Is improved, installed or replaced by the homeowiier or licensed contractor. <br /> Skip next sectiou, i�f this applies; Cost of Pernut $ 15.00 <br /> State Surcharge � .�0 <br /> Mail-In Fee (If Applicable) $ 1.50 <br /> T'otal Permit F'ee � <br /> (Permit Fees Continued On Next Page) <br /> � <br />