NCC216042_FRO Submitted_20211101

EM-0 WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity on one or more acres as covered by the Wake
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
NORTH CAROLINA 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 JS Commerce Park - Wilmington Road Re -Alignment
2. Location of land -disturbing activity: Jurisdiction Garner (Wake Co. or Municipality)
Highway/Street Wilmington Rd. Latitude 35.7192 Longitude-78.5914
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): 5.9 Ac.
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name John Core E-mail Address [e-mail]
7
Telephone [phone] Cell # 919-521-2262 Fax #
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
City State
8. Deed Book No. 8557
n/a
[e-mail]
Fax or E-mail address
Current Street Address
27615 Raleigh NC 27615
Zip City State Zip
Page No. 1694 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):
HMBP - BCP LLC [e-mail]
Name E-mail Address
104 Lake Cliff Court 104 Lake Cliff Court
Current Mailing Address Current Street Address
Cary NC 27513 Cary NC 27513
City State Zip City
Telephone [phone] Fax Number.
n/a
State
Zip

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 & 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:
Timothy C. Shaughnessy n/a
Name of Registered Agent E-mail Address
500 East Morehead St., Suite 200 500 East Morehead St., 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
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.
Gregg Sandreuter Member, HMBP - BCP LLC
Type or. ri ame Title or Authority
A ,
6
Signa Date
1, CA"t4gP °N m. jilt. a Notary Public of the County of WA V-6'
State of North Carolina, hereby certify that 4i "6W? EvTEiZ 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 Lf day of ��yvyr , 20_n?,L_
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