North Bend, WA · King County
Cross-Connection Non-Residential Survey Questionnaire
North Bend asks customers or businesses to complete this questionnaire after a plumbing permit is applied for, so the Water Department can assess possible cross-connections.
What this form is
The City of North Bend requires this questionnaire when a plumbing permit has been applied for at the address, to determine whether a cross-connection has been made with the city’s water supply. It asks for customer or business and site details, business type, and applicable activities or equipment, with space to describe other possible cross-connection concerns. The form is for preliminary assessment; the water purveyor may require a more thorough assessment later.
Who needs it
A customer or business at an address where a plumbing permit has been applied for must complete and return the questionnaire.
How to submit it
Mail the completed form to City of North Bend Water Dept, 920 SE Cedar Falls Way, North Bend, WA 98045, or email it to [email protected].
About notarization
No notary is required; the person completing the form provides their name and date, and no sworn or notarized attachment is listed.
How to submit this form
- 1
Download The Questionnaire
Download the Cross-Connection Non-Residential Survey Questionnaire.
- 2
Complete The Form
Provide customer or business, site, mailing, phone, and business-type information, then check applicable items and describe other concerns.
- 3
Add Name And Date
Enter the name of the person completing the questionnaire and the date.
- 4
Submit To The Water Department
Mail the completed form to the Water Department at 920 SE Cedar Falls Way or email it to [email protected].
Frequently asked questions
- Do I need a notary for the Cross-Connection Non-Residential Survey Questionnaire?
- No. The questionnaire has no notary block or notarized attachment listed. The person completing it provides their name and date.
- Who must complete the questionnaire?
- The city asks the customer or business at an address where a plumbing permit has been applied for to complete the questionnaire.
- What information does the survey ask for?
- It asks for customer or business and site information, the type of business, and whether listed activities or equipment are present. It also provides space to describe other possible cross-connection concerns.
- How do I submit the Cross-Connection Non-Residential Survey Questionnaire?
- Mail the completed form to City of North Bend Water Dept, 920 SE Cedar Falls Way, North Bend, WA 98045, or email it to [email protected].
Need something notarized?
This Cross-Connection Non-Residential Survey Questionnaire doesn’t need a notary — but if you have another North Bend form that does, a commissioned online notary can help.