NCC240534_FRO Submitted_20240223

Wil WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
tiVAKE No person may initiate any land-disturbing activity on one or more acres as covered by the Wake
County Unified Development Ordinance before this form and an acceptable erosion and
COUNTY sedimentation control plan have been completed and approved by Wake County Department of
Noicri� :, >� �,, Environmental Services, Water Quality Division. (Please type or print and, if the question is not
applicable, place N/A in the blank.)
Part A.
1. Project Name +/- 14,000-SF Dental Surgery Center for Valleygate Dental
2. Location of land-disturbing activity: Jurisdiction Garner (Wake Co. or Municipality)
Highway/Street 305 Timber Dr. Latitude 35.686 Longitude 78.608
3. Approximate date land-disturbing activity will commence: 11/01/2023
4. Type of development(residential, commercial, industrial, institutional, etc.):Commercial
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): 2.26
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Sharif Aziz E-mail Address [e-mail]
Telephone [phone] Cell# Fax#
7. Landowner(s)of Record (attach accompanied page to list additional owners):
Wake Real Estate Partners, LLC 910-485-7070 [e-mail]
Name(s) Telephone Fax or E-mail address
2028 Litho Place Suite 300 2028 Litho Place Suite 300
Current Mailing Address Current Street Address
Fayetteville NC 28304 Fayetteville NC 28304
City State Zip City State Zip
8. Deed Book No. 19281 Page No. 1592 Provide a copy of the most current deed.
Part B.
1. Person(s) or firm(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet. Include requested information):
Fitts and Goodwin, Inc. [e-mail]
Name E-mail Address
200 Cascade Pointe Lane, Ste. 101 200 Cascade Pointe Lane, Ste. 101
Current Mailing Address Current Street Address
Cary NC 27513 Cary NC 27513
City State Zip City State Zip
Telephone [phone] Fax Number

2. (a) If the Financially Responsible Party is not a resident of Wake County, identify a designated agent in
Wake County to receive any notice, process, pleading in any action or legal proceeding arising out of any
matter relating to the Wake County Erosion and Sedimentation Control Ordinance and/or Land
Disturbance Permit:
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, attach a copy of the Certificate of Assumed Name. If the Financially Responsible
Party is a Corporation, give name and street address of the Registered Agent:
Thomas Fitts [e-mail]
Name of Registered Agent E-mail Address
120 Corporate Blvd. 120 Corporate Blvd.
Current Mailing Address Current Street Address
West Columbia SC 29169 West Columbia SC 29169
City State Zip City State Zip
Telephone [phone] Fax Number
The above information is true and correct to the best of my knowledge and belief and was provided
by me under oath (This form must be signed by the Financially Responsible Person if an individual
or his attorney-in-fact, or if not an individual, by an officer, director, partner, or registered agent with
the authority to execute instruments for the Financially Responsible Person). I agree to provide
corrected information should there be any change in the information provided herein.
Thomas Fitts President
Type or
rat na, e Title or Authority
� � l I '2
Signature Date
I, mt , c, , a Notary Public of the County of IZ 1 cln lct''o(
State of North Carolina, hereby certify that appeared
personally before me this day and being duly sworn acknowledged that the above form was executed by him.
Witness my hand and notarial seal, this _7 day of Iv ,a.t'11� , 20 '2
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Notary l
Seal • 6
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