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� <br /> I�LI�BIl�T�� �'�EING INSTALLE�7 <br /> FIXTURE BSMT 1 2 OTHER FIXTURE BSMT 1 2 O'THER <br /> TYPE FL FL TYPE FL FL <br /> Water Closet 1 1 3 Fl�r Drains � <br /> Lavatory � 1 5 Sewer Ejector <br /> Bathtub 2 Laundry Tray 1 <br /> Shower � � Washer � <br /> Kitchen Sink � Water Heater � <br /> Disposal � Water Softener � <br /> Dishwasher � Wet Bar � <br /> Sillcocks 2 Miscellaneous <br /> ; <br /> ���[T r����..��,�.�arr��j <br /> f �� BA��i�4F�'-200��T`�"TE STATUE' <br /> ❑ Yes,this section applies <br /> The replacement of a Residential fi�cture or appliance that meets all three of the following reyuirements: <br /> 1. Does not require modification to electrical or gas service. <br /> 2. Has a 1 ost of$500.00 or less;excluding the cost of the�xture or appliance:and <br /> 3. Is improved,installed or replaced by the homeowner or licensed contractor. <br /> Skip next section,if this applies; Cost of Permit $ 15.00 <br /> State Surchaxge $ .50 <br /> Mail-In Fee(If Applicable) $ 2.00 <br /> Total Permit Fee S <br /> (Permit Fees Continued On Next Page) <br /> 2 <br />