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�,, . . � <br /> . <br /> , a � < � , y ,� <br /> �;s � -� � � � � ��. ��,� ���. <br /> � <br /> -� <br /> ' - � ��.�� , . _�� . ����,�,_. <br /> . <br /> �: . _ .:.� _ � � <br /> FIXTURE BSMT 1 T ZND OTHER FIXTURE BSMT 1 T 2ND pTHER <br /> TYPE FL FL TYPE FL FL <br /> Water Closet j I Floor Drains I <br /> � <br /> Lavatory � � Sewer Ejector <br /> Bathtub 1 1 Laundry Tray <br /> Shower Washer <br /> Kitchen Siuk � Water Heater <br /> Disposal Water Softener ' <br /> Dishwasher Wet Bar <br /> Sillcucks Miscellaneous , I, ,� <br /> ���-�� <br /> i <br /> ' S � R �' �>d ''� ��v� � m a �* . <br /> � �� 4��3�"'�2���tv��"�"a��� ..0. �Y�,�� �� � ��� �� y-. <br /> k- <br /> _ 6 ��" ,�'' �y �� Aq�� a,` � �41� � ��� ��7 1 "� <br /> ._a�`"a ,r �;t a �" yz?� ����'^ � '�� . a"�r 4'�i�����k` <br /> ❑ Yes,this section applies <br /> The replacement of only one Residential fixture or appiiance that meets all three of the following <br /> requirements: <br /> 1. Does not require modification to electrical or gas seivice. <br /> 2. Has a total cos of$500.00 or less; excludinQ the cost of the fixture or appliance:and <br /> 3. ls improved,installed or replaced by the homeowner or licensed plumbing contractor. <br /> Skip next section,if this applies; Cost of Pennit $ 15.00 <br /> State Surcharge $ 5.00 <br /> Mail-In Fee(If Applicabte) $ 2.00 <br /> Total Permit Fee $ <br /> (Permit Fees Continued Un Next Page) <br /> 2 <br />