NCC223189_FRO Submitted_20220912

W�w WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
77�W�AXME
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
sedimentation control plan have been completed and approved by Wake County Department of
NUR YF1 CA R01f NA 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 Beacon Commerce Park - Building 3
2. Location of land -disturbing activity: Jurisdiction Garner (Wake Co. or Municipality)
Highway/Street Manes Sausage Rd. Latitude 35.715129 Longitude.-78.590556
3. Approximate date land -disturbing activity will commence: June 15, 2021
4. Type of development (residential, commercial, industrial, institutional, etc.): Industrial
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas): 20.1 Ac.
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name John Core _ E-mail Address [e-mail]
Telephone [phone] Cell # 919-521-2262 Fax #
7. Landowner(s) of Record (attach accompanied page to list additional owners):
Doggett Associates, LLC 919-971-2821
Name(s) Telephone
8324 La Matisse Road 8324 La Matisse Road
Current Mailing Address
Raleigh NC 27615
City State Zip
8. Deed Book No. 8557 Page No.
[e-mail]
Fax or E-mail address
Current Street Address
Raleigh NC 27615
City State Zip
1694 Provide a copy of the most current deed.
4095 172
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):
HMBP - BCP LLC [e-mail]
Name E-mail Address
500 East Morehead, Suite 200 500 East Morehead, Suite 200
Current Mailing Address Current Street Address
Charlotte, NC 28202 Charlotte, NC 28202
City State Zip City State Zip
Telephone [phone] Fax Number n/a

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:
Greg Sandreuter
Name
_ 104 Lake Cliff Ct.
Current Mailing Address
Cary NC 27513
City State Zip
Telephone [phone]
[e-mail]
E-mail Address
104 Lake Cliff Ct.
Current Street Address
Cary NC 27513
City State Zip
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:
Timothy C. Shuaghnessy
Name of Registered Agent
500 East Morehead St., Suite 200
Current Mailing Address
Charlotte
City
NC 28202
State Zip
Telephone [phone]
n/a
E-mail Address
500 East Morehead St., Suite 200
Current Street Address
Charlotte
City
Fax Number n/a
NC 28202
State Zip
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.
Manager, HMBP-BCP LLC
Title or Authority
S a7 Dt0_-)_
Date
a Notary Puplic of the County of
State of North Carolina, hereby certify that
personally before me this day and being duly sw!orn aj
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Witness my hand and notarial seal, this A/'—daof
Seal Notary Pu
Mecklenburg
County
- 20 .=
M O .�
DtJ L_ U�v
vledoed that the above
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appe red
was executed by him.
.
commission expires4-A/1� /