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� � + � <br /> .��c''��a�,,s.,,: r� <br /> FIXTURE BSMT 1 2 OTI�R FIXTURE BSMT 1 2 OTF�R <br /> TYPE FL FL TYPE FL FL <br /> Water Closet I 2 2 Floor Drains I <br /> Lavatory 2 � Sewer Ejector <br /> Bathtub I , Laundry Tray ' <br /> Shower � Washer � <br /> Kitchen Sink ` Water Heater <br /> Disposal Water Softener <br /> Dishwasher Wet Baz � <br /> Sillcocks Miscellaneous <br /> ?�,�: <br /> . _ <br /> ��:. <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;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 $ 1.00 <br /> Mail-In Fee(If Applicable) $ 2.00 <br /> Total Permit Fee $ <br /> (Permit Fees Continued On Nezt Page) <br /> 2 <br />