MEDICAL GAS
PERMIT APPLICATION
Grove City Building Division
4035 Broadway
Grove City, OH 43123
614-277-3075 (Phone)
614-277-3090 (Fax)
GroveCityOhio.gov
24-Hour Inspection Line: 614-277-1815
For next business day inspections, requests must be called in before noon or contractors may use the online inspection service as late as 8 p.m., seven days a week.
PROPERTY INFORMATION
Address ____________________________________________________________________________________________ Grove City, OH 43123
Parcel I.D.
_________________________________ Unit/Suite/Building _____________________________________ Zoning ______________
OWNER INFORMATION
Name _______________________________________________________________ Phone ____________________________________________
Address _____________________________________________________________ Email _____________________________________________
Permit No. ______________________________________________________________________
Method by which you would like your permit returned: o Fax o Email o Pickup
NO PART OF ANY MEDICAL GAS SYSTEM SHALL BE
COVERED UNTIL IT HAS BEEN INSPECTED, TESTED
AND APPROVED.
CALL FOR FINAL INSPECTION WHEN JOB
IS COMPLETE AND BEFORE SYSTEM USE.
PERMIT MUST BE POSTED ON SITE.
FEES
PERMIT FEES
____ Systems x $100 $ ____________
____ Outlets x $15 $ ____________
PLANS REVIEW
1-10 Systems = $100 $ ____________
11-30 Systems = $200 $ ____________
31> Systems = $250 $ ____________
Subtotal $ ____________
State Fee 3% $ ____________
Total Fees Due $ ___________________
MEDICAL GAS PERMIT INFORMATION
TYPE OF SYSTEM NO. OF SYSTEMS NO. OF OUTLETS
Carbon Dioxide
Helium
Instrument Air
Medical Air
Medical/Surgical Vacuum
Nitrogen
Nitrous Oxide
Oxygen
Waste Anesthesia Gas Disposal
Other
Total
CONTRACTOR INFORMATION Registration No. ______________________________________________
Contractor ______________________________________________________________ Contact ________________________________________
Address ________________________________________________________________ City/State/Zip___________________________________
Phone
________________________ Fax __________________________ Email ______________________________________________________
Signature
___________________________________________________________________________________________ o Owner o Agent
OFFICE USE
Receipt # __________________________
o Cash o Card o Check
Ref. # ______________________________
Date Entered ______________________
Date Issued ________________________
Approved ________ Date ___________
Revised 12/2019
