Andy ChabassolMIAMIBEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl.gov
Telephone: 305.673.7411
RECEIVED'
MAR 112074
CITY OF MIAMI BEACH
OFFICE OF THE CITY CLERK
AFFIDAVIT OF AFFILIATION WITH THE CITY OF MIAMI BEACH
I am in compliance with the affiliation requirement of Miami Beach City Code Sections 2-22 (4),
as ( check (/) all that apply):
or - A«aress. '[8 LJ 1" Sr_,L, L a, he..d, F, 33i
r Aso = 47o Pe fe b«, ] la,] teak, F, 3379 L ] have an ownership interest (for a minimum oi six mon~sj in a business established in the'
City of Miami Beach (for a minimum of six months).
[are f [ys[nesS._
Business Address: ------------------------- □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 of Business: -------------------------
Business Address: -------------------------
"Ownership Interest" means the ownership of ten percent (10%) or more (incl uding 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.
6lare that I have read the foregoing document and that the facts
Signature
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9/2/ 22$
Date '
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