DISCLOSURE FORM
(Form 3 of 5)
Project Title: Jane Dispensary 4040 Sonoma Highway, Santa Rosa, CA 95409 (Include site address)
Please provide the name of each individual, partnership, corporation, LLC, or trust who has an interest in the proposed land use action. Include the names of all applicants, developers, property owners, and each person or entity that holds an option on the property.
Individuals: Identify all individuals
Partnerships: Identify all general and limited partners Corporations: Identify all shareholders owning 10% or more of the stock and all officers and directors (unless the corporation is listed on any major stock exchange, in which case only the identity of the exchange must be listed.
LLCs: Identify all members, managers, partners, officers and directors.
Trusts: Identify all trustees and beneficiaries.
Option Holders: Identify all holders of options on the real property.
Full Name: Address:
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In addition, please identify the name of each civil engineer, architect, and consultant for the project.
Full Name: Address:
Additional names and addresses attached: (Yes □ No
The above information shall be promptly updated by the applicant to reflec ny change that occurs prior to final action.
Attachment 1
DISCLOSURE FORM
(FORM 3-5)
Project Title: JANE Dispensary 4040 Sonoma Highway, Santa Rosa, CA 95409
Please provide the name of each individual, partnership, corporation, LLC, or trust who has an interest in the proposed land use action. Include the names of all applicants, developers, property owners, and each person or entity that holds an option on the property.
Full Name Address
JANE 4040, Inc (Corp applying for CUP – 4 owners below) 1030 2nd Street Ste 2A, Santa Rosa, CA 95404
*Mario Tamo (25% owner JANE 4040, INC) 1030 2nd Street Ste 2A, Santa Rosa, CA 95404
*Randall Waller (25% owner JANE 4040, INC) 1030 2nd Street Ste 2A, Santa Rosa, CA 95404
*Greg Windisch (25% owner JANE 4040, INC) 1030 2nd Street Ste 2A, Santa Rosa, CA 95404
*Anthony Shira (25% owner JANE 4040, INC) 1030 2nd Street Ste 2A, Santa Rosa, CA 95404
CORHAL, LLC (Property Owner – 3 owners below) 7215 Oak Leaf Dr, Santa Rosa, CA 95409
*Brian and Lori Hall (33% owner Corhal, LLC) 7215 Oak Leaf Dr, Santa Rosa, CA 95409
*Susan Corso (70% owner Corhal, LLC) 7215 Oak Leaf Dr, Santa Rosa, CA 95409
In addition, please identify the name of each civil engineer, architect, and consultant for the project.
Full Name Address
ARCHITECT
Beving Architecture – Mica Beving PO Box 154, Ventura, CA 93002
MECHANICAL ENGINEER
15000 inc. – Matthew Torre, PE/Principal 6085 State Farm Dr. #130, Rohnert Park, CA 94928
CONSULTANT – Lighting/Energy
Delta T Energy Consulting – Roy Asti 6050 Commerce Blvd STE 203, Rohnert Park, CA 94928