Instrument Prepared By: RaleighCity Attorney’s Office

Brief Description for Index:______

Property I.D. Number:______

Mail After Recording To:City of Raleigh

DevelopmentServicesCustomerServiceCenter

PO Box 590

Raleigh, NC 27602

RELEASE, CONSENT, AND NOTICE

NON-STANDARD SANITARY SEWER INSTALLATION

THIS RELEASE, CONSENT, AND NOTICEis made and given this ____ day of ______, 20___, by ______

______, hereinafter referred to as the “Owners”, to the City of Raleigh, a North Carolina Municipal Corporation.

WITNESSETH:

WHEREAS, the Owners are the ownersof property located at ______

______, having the legal description as follows: ______; and

WHEREAS, the Owners desire to install or have installed, at the building or buildings located at the above referenced address, weirs of traps from plumbing fixtures or drains which are lower than the elevation which is 1 foot above the top of a sewer main manhole located upstream from the building sewer connection serving the traps (the “plumbing installation” or “installation”); and

WHEREAS, pursuant to §10-6084 of the Raleigh City Code, such installation does not conform to the standards of the City of Raleigh and, accordingly, will not be allowed unless and until a Release, in recordable form, is executed and given to the City by the Owners; and

WHEREAS, upon execution by the Owners and recordation of this instrument by the City, the Owners may make and use such plumbing installation, subject to terms and conditions set forth herein.

NOW, therefore, in consideration of the premises, the mutual benefits accruing hereunder to the City, the Owners, and the public, and for other good and valuable consideration, the Owners do hereby RELEASE AND DISCHARGE the City of Raleigh, it’s officers, employees, and agents, from any and all liability for claims, damages and causes of action which may result from sewage backflow from the Owners’ premises identified above.

IT IS FURTHER ACKNOWLEDGED AND AGREED by the City, upon acceptance and recordation of this instrument, that the plumbing installationmay be installedand/or continued in use, as applicable, by the Owner, their heirs, successors and assigns, subject to terms and conditions hereof. Accordingly, for so long as the plumbing installation continues in service, these covenants shall run with the above-described property, and be binding upon the Owners’ heirs, successors and assigns.

APPLICATION AND RELEASE APPROVED:

BY:(INSPECTOR)______(DATE)______

IN WITNESS WHEREOF, the Grantor has caused this instrument to be signed in its corporate name by its (Vice) President, by order of its Board of Directors, and as the act and deed of the Corporation, this the day and year first above written.

______

(NAME OF CORPORATION)

By:______

______

(Vice) President

APPROVED AS TO FORM:

______

(Deputy) City Attorney

NORTH CAROLINA

COUNTY OF WAKE

I, ______, a Notary Public for ______County, North Carolina, do hereby certify that ______

Personally came before me this day and acknowledged that (s)he is (Vice) President of ______corporation and acknowledged, on behalf of ______corporation, the grantor, the due execution of the foregoing instrument.

Witness my hand and official seal, this the ______day of ______, 200__.

(Notary Seal)______

______, Notary Public Notary’s printed or typed name

My commission expires:______