Richard Segal 12/31/21Richard Segal 1/13/2021
Board of Adjustment City Commission
12/31/21 12/31/21
1/20/2021 1/25/2021
1/25/2021
1/25/2021
1/25/2021
25th Jan
#
B
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florido 33139
OFFICE OF THE CITY CLERK
Email: BC@m iamibeachf_gov
Telephone: 305.673.7411
AFFIDAVIT OF AFFILIATION WITH THE CITY OF MIAMI BEACH
STATE OF FLORIDA
COUNTY OF
I am in compliance with the affiliation requirement of Miami Beach City Code Sections 2-22 (4),
as (check (/) all that apply):
lS lam a resident of the City of Miami Beach for six months or longer.
[] Ihave an ownership interest (for a minimum of six months) in a business established in the
City of Miami Beach (for a minimum of six month s).
[] lam a full-time employee of a business (for a minimum of six months) and I am based in an
office or other location of the business that is physically locat ed in Miami Beach (for a
minimum of six months).
"Ownership Interest" means the ownership of ten percent (10%) or more (including the
ownership of 10% or more of the outstanding capital stock) in a business.
"Business" means any sole proprietorship, sponsorship, corporation, limited liability company,
or other entity or business association.
Un der penalties of perjury, I declare, that I have read the foregoing documen t and that the facts " .o Signature Date
U A 5<«
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of physical presence or online
notarization, this 25th day of January 20l_by
Richard Segal (City of Miami Beach Board/Com mittee Member).
FL Drivers License X Produced ID
Form of Identification
Personally Known
Ciao t'get
Signature of Notary Public.
Charles J D'Agostin
Name of Notary, Typed, Printed, or Stamped
(NOTARY SEAL)
Charles J. DAgostin
NOTARY PUBLIC
STATE OF FLORIDA
Comm# GG168171
Cr? Expires 12/14/2021
X
Received on January 25, 2021Office of the City Clerk