Project Title:
(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:
Partnerships:
Corporations:
LLCs:
Trusts:
Identify all individuals
Identify all general and limited partners
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.
Identify all members, managers, partners, officers and directors.
Identify all trustees and beneficiaries.
Option Holders: Identify all holders of options on the real property.
Full Name: Address:
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 reflect any change that occurs prior to final action.
I certify that the above information is true and correct:
Applicant Date
DISCLOSURE FORM
(Form 3 of 5)
Montgomery Village, 911 Village Court, Santa Rosa, CA 95405 Please see attached disclosure form.
Summit Engineering, Inc
463 Aviation Blvd, Suite 200, Santa Rosa CA 95403
9/20/2022
DocuSign Envelope ID: EA317B34-423B-48E1-B859-3F962A76891E Attachment 1
DISCLOSURE FORM ATTACHMENT
Party Full Name: Address:
Landowner and Party
with interest in
proposed Land Use
Action
Montgomery Village
Owner LLC
33 Boylston St., Suite 3000, Chestnut
Hill, MA 02467
Sole Member and
Manager of
Montgomery Village
Owner LLC
Montgomery Village
Venture LLC
33 Boylston St., Suite 3000, Chestnut
Hill, MA 02467
Officer of
Montgomery Village
Owner LLC
Jeremy M. Sclar, President 33 Boylston St., Suite 3000, Chestnut Hill, MA 02467
Officer of
Montgomery Village
Owner LLC
Thomas J. DeSimone, VP
& Treasurer
33 Boylston St., Suite 3000, Chestnut
Hill, MA 02467
Officer of
Montgomery Village
Owner LLC
Richard A. Marks, VP &
Secretary
33 Boylston St., Suite 3000, Chestnut
Hill, MA 02467
Officer of
Montgomery Village
Owner LLC
Samantha Perry David, VP 33 Boylston St., Suite 3000, Chestnut Hill, MA 02467
Officer of
Montgomery Village
Owner LLC
Eric S. Smookler, VP &
Asst. Treasurer
33 Boylston St., Suite 3000, Chestnut
Hill, MA 02467
Officer of
Montgomery Village
Owner LLC
Daniel B. Preysman, VP &
Asst. Secretary
33 Boylston St., Suite 3000, Chestnut
Hill, MA 02467
DocuSign Envelope ID: EA317B34-423B-48E1-B859-3F962A76891E