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r <br /> � <br /> PL� t= �����"�. :,3�. <br /> FIXTURE BSMT 1 2 OTI-�R FIXTURE BSMT 1 2 OTI-IER <br /> TYPE FL FL T'YPE FL FL <br /> Water Closet Floor Drains � <br /> Lavatory Y Sewer Ejector <br /> (� <br /> Bathtub Laundry Tray <br /> Shower � Washer <br /> Kitchen Sink Water Heater <br /> Disposal Water Softener <br /> Dishwasher Wet Bar <br /> Sillcocks Miscellaneous <br /> � t.� �A'������ ��A�� ;�_ � ; .��� <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 Perrnit $ 15.00 <br /> State Surcharge $ 5.00 <br /> Mail-In Fee(If Applicable) $ 2.00 <br /> Total Permit Fee $ <br /> (Permit Fees Continued On Next Page) <br /> 2 <br />