Josh LevyRECEIVED
City of Miami Beach QCC 14 2021
1700 Convention Center Drive
Miami Beach, Florida 33139
CITY 4F MIAMI BEACH
CtF.171r' ~ QIF THE CITY CLERIC
OFI ICE OF THE CITY CLERK
Email: BC(cilmiamibeachfl gov
Telephone: 305.673.7411
AFFIDAVIT OF AFFILIATION WITH THE CITY OF MIAMI BEACH
I am in ompliance with the affiliation requirement of Miami Beach City Code Sections 2-22 (4),
as (c ck (✓) all that apply):
I am a resident of the City of Miami Beach for six months or longer.
Home 2 3
Address: J
L�
l /4.1; P 3,--1Y3
I have an ownership interest (for a minimum of six months) in a business established
in the City of Miami Beach (for a minimum of six months).
Name Busn ss: 1 /`� L— /"c/J P
of
Businessn 22 6 �^ 1
Address: > 5 11, 41 � � A( � J 31 LID
❑ I am 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 located in Miami Beach
(for a minimum of six months).
Name
Business:
Business
Address:
of
"Ownership Interest" means the ownership of ten percent (105/6) 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.
Under penalties of perjury, I declare that I have read the foregoing document and that the facts
stated in it are true. I
Signature Date I &/fir