Jacob Intrator 04.01.25MIAMI BEACH
BOARD AND COMMITTEE CHECKLIST
APPOINTEE:_Io \Ab DATE OF APPOINTMENT:_(Co [2?o[3]'(
oARDrcoMrrrEE:£p A Si44 40biog Appointed by.'by {'comic=oo
,o di-o Co6FORSCANNERFORCLERKSTAFF ••
scan o o Letter of Appointment TERM END:].O\.OS TERM LIMIT:[.Q\[.S
Scan o o Letter of Reappointment
o Copy of Letter of Appointment/Reappointment e-mailed to Committee Liaison on _]I3[L2]
Scan o o Board and Committee Application (Completed on 28 2-T
Scan o o Resume/Curriculum Vitae
o Diversity Statistics Reporting (Completed on [3]2d
Scan o o Oath t
RECEIVED
AUG 06 2024
CITY OF MIAMI BEACHOFFICEOFTHECITYCLERK
Scan o
Scan o
IMPORTANT INFORMATION FOR BOARD AND COMMITTEE MEMBERS BOOK
✓City Code Ordinance Section applicable to the agency,board or committee
✓City Code Sections 2-21,2-22,2-23,2-24,2-25,2-26,2-458 and 2-459
✓County Code Section 2-11.1 --Conflict of Interest and Code of Ethics Ordinance (as
amended through December 2010)
✓Amendments to the Code of Ethics Ordinance (September 2009 through July 2012)
✓Highlights of the Miami-Dade County Ethics Code
✓Sunshine Law and Public Records -Frequently Asked Questions
✓Memorandum -Solicitation by City Board and Committee Members
o Citywide Permit Application (Parking Department Form)
o Booklet -Guide to Sunshine Amendment &Code of Ethics for Public Officers and Employees
o Source of Income Statement
o Acknowledgment Statement
o Board and Committees Liaison Responsibilities
o Diversity Statistics Reporting
el acknowledge that pursuant to Sec.2-22(9)of the Miami Beach Code of Ordinances,I will be removed
from my board/committee upon failure to attend 33%of the regularly scheduled meetings.
Sec.2-22(9)If any member of an agency,board or committee fails to attend 33 percent of the regularly scheduled
meetings per calendar year,such member shall be automatically removed.To calculate the number of absences
under the 33 percent formula,.4 or less rounds down to the next whole number and .5 or more rounds up to the
next whole number.
NOTE:Members of the Land Use Boards will be removed upon failure to attend three of the regularly scheduled
meetings per calendar year;or upon abstaining from voting due to a conflict of interest on four different
applications within a calendar year.A member who is removed shall not be reappointed to membership on the
board for at least one year from the date of removal.
Received on:o7/o3/2024 X fee6fiat.ate}lgned Dy 1/
Date
dotloop verified08/02/24 5.58 PM EDTQ0L4-L9KI-KACO-AFIR
Board or Committee Member
Processed on:6]e\2YBy Employee:ht.
Date City Clerk's Office Staff Initials
We are committed to providing excellent public service and safety to all who live,work,and play in our vibrant,tropical,historic community.
MIAMI BEACH
City of Miami Beach,1/OO Convonlion Conlor Drive,Miami Boach,Florida 33 139 yyyy._miamibcachll.gov
OFFICE OF THE CITY CLERK,Rafael E.Granado,CyClerk
Tel:305.673.7411,Fax.305.673.7254Email:CiyClerk@miamibeachll.gov
June 28,2024
Mr.Jacob lntrator
1500 Ocean Drive
Miami,Florida 33139
RE:Ad Hoc CityLighting Plan Advisory Committee
Dear Mr.Jacob lntrator:
Congratulations!You have been appointed by the City Commission to the agency,board or committee
named above for a term ending:04/01/2025.
If you are unable to accept this appointment,or have any questions,please call the Office of the City
Clerk at 305.673.7411.
Please read the enclosed materials carefully as they concern your duties,responsibilities,and
requirements as a board or committee member.
Congratulations again and good luck.'ia.tie
City Clerk
cc:Jose Gonzalez,Parking Director
Joe Gomez,City Liaison
ENCLOSURES:
Oath of Office/Oath of Civility/Acknowledgements
City Code/Ordinance section applicable to agency,board or committee
City Code Section 2-22,2-23,2-24,2-25,2-26,2-458 and 2-459
Ordinance No.2006-3543 -Amendment to City Code Section 2-22
Miami-Dade County Code Section 2-11.1 -Conflict of Interest and Code of Ethics
City Wide Permit Application -(Parking Department Form)
Booklet -Guide to the Sunshine Amendment and Code of Ethics for Public Officers and Employees
MIAMI BEACH
City of Miami Beach,1/00 Convention Canter Drive,Miami Boach,Florida 33 139 wwwy_miaIiboachf]go
OFFICE OF THE CITYCIERK,Raf0ol E.Granado,City Clerk
Tel:3O5.673.7411,Fax.305.673.7254
Email:Ci#yClerk@miamiboochfl.gov
Oath of Office
Oath of Civility
and
Acknowledgements
TO:Mr.Jacob lntrator
RE:Ad Hoc City Lighting Plan Advisory Committee
I do solemnly swear or affirm to bear true faith,loyalty and allegiance to the Government of the United
States,the State of Florida,and the City of Miami Beach,and to perform all the duties of a member of the
above-mentioned board or committee of the City of Miami Beach to which I have been appointed for a
term ending:04/01/2025.
To my colleagues and to all of those I represent and serve,I pledge fairness,integrity and civility,in all
actions taken and all communications made by me as a public servant.
I have been issued a copy of section 2-11.1 of the Miami-Dade County Code (Conflict of Interest and
Code of Ethics Ordinance),as well as Florida Commission on Ethics Guide to the Sunshine Amendment
and Code of Ethics for Public Officers and understand that as a member of a City of Miami Beach Board
and/or Committee,I must comply with the financial disclosure*requirements of Miami-Dade County or the
State of Florida (depending on the board or committee on which I serve)on July 1st,following the closing
of the calendar year on which I have served.
dotloop verified08/02/24 6.03 PM EDTYLIO-JNRJ-FSXL-VWWP
Mr.Jacob lntrator
Sworn to and subscribed before me this _z-2024---
llice Lavado
Deputy Clerk
*Please visit the City of Miami Beach website at www.miamibeachfl.gov under City Clerk/Board and
Committees for additional information regarding the Financial Disclosure Requirements.
MIAMI BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach,Florida 33139
RECEIVED
AUG 07 2024
CITY OF MIAMI BEACHOFFICE+"IE CITY CLERK
OFFICE OF THE CITY CLERK
Email:BC@miamibeacht].gov
Telephone:305.673.7411
AFFIDAVIT OF AFFILIATION WITH THE CITY OF MAM BEACH
I am in compliance with the affiliation requirement of Miami Beach City Code Sections 2-22 (4),
as (check (✓)all that apply):
I &If I am a resident of the City of Miami Beach for six months or longer.
Home AddreSS.[1500 Ocean Drive,33139[
D 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).
fame of BusineSS/_-------
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:------------------------
H3ys/nesS ddreSS._.---
"Ownership Interest"means the ownership of ten percent (10%)or more (including theownershipof10%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"3caSignature Date
pacob lntrator
Printed Name
..
MIAMI BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach,Florida 33139
www.miamibeachll,gov
OFFICE OF THE CITY CLERK
Email:BC@miamibeachfl.gov
Telephone:305.673 .7411
DIVERSITY STATISTICS REPORT
Intrator
Last Name
Jacob
First Name Middle Initial
The following information is voluntary and has no bearing on your consideration for appointment.It is being
asked to comply with City diversity reporting requirements.
Gender:
[)MaleDFemalelonerDIprefer not to answer.
Race/Ethnic Categories:
What is your race?D African American/Black
LlAsan or Pacific Islander
[al Caucasian/whiteDNativeAmerican/American Indian0Other-Print Race:_D I prefer not to answer.
Do you consider yourself to be Spanish,Hispanic,or Latino/a?
LlvesAoDIprefer not to answer.
Do you consider yourself Physically Disabled?
Lves
a»Ro
Ll1refer not to answer this question.
Page 6 of 6
F:ICLER\$ALL\REGIBOARD AND COMMITTEE APPLICATIONS FINAL DRAFTS\BOARD AND COMMITTEE APPLICATION REG FINAL.docx
Updated:June 2020
MIAMI BEACH
City of Miami Beach
1 700 Convention Center Drive
Miami Beach,Florida 331 39
www.miamibeachfl.gov
OFFICE OF THE CITY CLERK
Email:BC@miamibeachfl.gov
Telephone:305.673.7411
Intrator
Last Name
BOARD &COMMITTEE ACKNOWLEDGEMENT STATEMENTS
Jacob
First Name Middle Initial
Acknowledgment of fines/suspension for Board/Committee Members for failure to comply with Miami-
Dade County Financial Disclosure Code Provision Code Section 2-11.1(i)(2)
I understand that no later than July 1,of each year all members of Boards and Committees of the City of Miami
Beach,including those of a purely advisory nature,are required to comply with Miami-Dade County Financial
Disclosure Requirements.
One of the following forms must be filed with the City Clerk of Miami Beach,1700 Convention Center Drive,
Miami Beach,Florida,no later than 12:00 noon of July 1,of each year:
1.A "Source of Income Statement;"or
2.A Copy of your latest Federal Income Tax Return.
Members of the Planning Board and the Board of Adjustment must electronically file a "Statement of Financial
Interests (Form 1)"directly with the Florida Commission on Ethics.
Failure to file one of these forms,pursuant to the Miami-Dade County Code,may subject the person to a fine
of no more than $500,60 days in jail,or both.
Acknowledgment to Comply with Miami Beach Code of Ordinances Sec.2-22 (23)
I understand that commencing with terms beginning on or after January 1,2024,and as a condition of applying
for appointment to a City agency,board,or committee,I voluntarily agree that in the event I file with the City
Clerk a Statement of Candidate formally announcing candidacy for City elective office,such filing with the City
Clerk shall be deemed a tender of resignation from the City agency,board,or committee.
Acknowledgment to Comply with Miami Beach Code of Ordinances Sec.2-22 (24)
I understand that if I am engaged to provide services,for compensation,to either (1)a candidate for City elected
office,or (2)a political committee or electioneering communications organization expending funds for or against
candidates for City elected office,such engagement shall be deemed a tender of resignation from the City
agency,board,or committee.
Signature
dotloopverified08/02/24 5:58 PM EDTNHKC-SYHU-NFRC-MHCI 08/02/2024
Date
1 Members of the Planning Board and Board of Adjustment will be notified directly by the State of Florida,
pursuant to F.S.§112.3145(1 )(a),to electronically file a Statement of Financial Interests (Form 1)with the Florida
Commission on Ethics by 12:00 noon,July 1.Planning Board and Board of Adjustment members who file their
Form 1 with the Florida Commission on Ethics automatically satisfy the County's financial disclosure requirement
as a Miami Beach City Board/Committee member and need not file an additional form with the Office of the City
Clerk.
Page 6 of 6
F:\CLER\$ALL\BOARD AND COMMITTEES DATABASE\Board and Committee Application\BOARD AND COMMITTEE APPLICATION JULY 2024.docx
Updated:July 2,2024
MIAMI-DADE.EII SOURCE OF INCOME STATEMENT
Section 2-11.1(i)of the County Ethics Code requires that certain employees and public officials file a financial disclosure Statement on a yearly basis by July 1stofeveryyear.
Disclosure for Tax Year Ending 'Last Name First Name Middle Name/Initial
2023
Mailing Address -Street Number,Street Name,or P.O.Box
City,State,Zip
If your home address is your mailing address,and your home address is exempt from public records pursuant to Fla.Stat.$119.07,read
instructions on the following page and check here.D
Filing as an Employee (check one)
[]county □Public Health Trust []Municipal:
(Municipality)
Department
Position or Title Employee ID Number
Work address I Work telephone Employment began on/ended on
Filing as a Board Member (check one)
[]county []Municipal:(Municipality)
Board where serving
Alternate address (if home address is exempt)Work telephone Term began on/ended on
List below every source of income you received,along with the address and the principal activity of each source.Include your public salary.Place the sources ofincomeindescendingorder,with the largest source first.Examples of sources of income include:compensation for services,income from business,gains frompropertydealings,interest,rents,dividends,pensions,IRA distributions,and social security payments.Also,include any source of income received by anotherpersonforyourbenefit.However,the income of your spouse or any business partner need not be disclosed.If continued on a separate sheet,check here.[]
Name of Source of Income Address Description of the Principal Business Activity
I hereby swear (or affirm)that tile information above is a true and correct statement.
Signature of Person Disclosing
Date signed
RECEIVED BY ELECTIONS DEPARTMENT:
D Hardcopy
D Electronic Copy
REMEMBER TO PRINT,SIGN,AND SUBMIT TO THE OFFICE OF THE CITY CLERK VIA EMAIL OR HARDCOPY.
MIAMI BEACHCityotMiamiBeach,PARKING DEPARTMENT
BOARD &COMMITTEES
PARKING APPLICATION IaPARKING1755MeridianAvenue,Suite 200 Miami Beach,FL 33139/Ph:(305)673-7505 or (305)673-7000 ext.6200
As a Board/Committee member you are entitled to a Citywide Parking Permit,which includes City Hall
garage (G7)parking access (Access Card),or a complimentary Citi Bike/Deco Bike Membership,or a
discounted MDC Monthly Transit Pass throughout your term.
Board Member Information
Date of Application:08/03/2024
Applicant Name:Jacob Intrator]
Board/Committee Name:H4Hoc City Lighting Planning IdvisoryCommittee
Address:2200sean [rive 33139
E-Mail Address:Jacob.Intrat@yahoo.com
Work Phone:B05-458-6213]Home Phone:p05-4586213
Cell Phone:B05-458-6213)Preferred Contact Method:
Please Choose One 1 0 tion:
Citywide Parking Permit/G7 Access Card [)}Citi Bike/Deco Bike Membership
Vehicle Information (For Citywide Parking Permit/Access Card Only)
Tag:Color:
State:Year:
Make:Model:
A citywide (CW)parking permit is honored at metered parking spaces and restricted residential zones
parking spaces.A CW parking permit IS NOT honored in prohibited areas.An Access Card will be
provided to you for City Hall Garage (G7)access.
IMPORTANT NOTE:Your vehicle license plate serves as your "parking permit".To avoid any
unnecessary enforcement actions,it is important that our records reflect the most current and
accurate information regarding your vehicle license plate.Inaccurate and/or outdated vehicle
information may lead to the issuance of parking citation(s)and/or the towing of your vehicle.
Please note that this new access card CANNOT be hole-punched or perforated in any manner.To use
the new card please hold the card at close proximity to the reader until the gate opens.You may
need to try the other side of the card.Please ensure you hold the entire surface of the card against
the reader until the gate opens.
ACKNOWLEDGEMENT:I acknowledge that should my access card be lost,stolen or damage,I will be
responsible to pay a $10.00 replacement fee.
Applicant Signature:
Please provide signed form to the Parking Department located at 1755 Meridian Avenue,2nd floor.
Working hours are 8:30 to 5:00 p.m.or email to:ParkingReception@miamibeachfl.gov
e-mail subject:BOARD &COMMITTEE PARKING APPLICATION -APPLICANT NAME
f;\ping\$man\rar\forms\cw boards&committees parkingform.doc form updated 1/18/2024