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Jonathan w. Cardello/1801 Collins Avenue~E: Ar a? MIAMIBEACH (~ a (~~``~ ~~ City of Miami Beach Office of the City Clerk 1700 Convention Center Drive, Miami Beach, FL 33139 LOBBYIST REGISTRATION FORM Lobbyist means all persons employed or retained, whether paid or not, by a principal who seeks to encourage the passage, defeat or modification of any ordinance, resolution, action or decision of any commissioner; any action, decision, recommendation of the City Manager or any city board or committee; or any action, decision or recommendation of any city personnel during the time period of the entire decision-making process on such action, decision or recommendation that foreseeably will be heard or reviewed by the city commission, or a city bond or committee. The term specifically includes the principaF as well as any employee engaged in lobbying activities. The term "Lobbyists" has specific exclusions. Please refer to Ordinance 2004-3435. Cardello Jonathan W. NAME OF LOBBYIST: (Last) (First) (M.L) c/o ADD, Inc. One Biscayne Tower, Suite 1670, Two South Biscayne Boulevard, Miami , FL 33131 BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) ~ (Zip Code) (305) 482-8700 (305) 482-8770 jcardello@addinc.com TELEPHONE NUMBER: FAX NUMBER: EMAIL: LOBBYIST RETAINED BY: Shelborne Associates, Costello Investments, Inc., Shelborne Ocean Beach Hotel Corp., and Beach Group III, LLC NAME OF PRINCIPAUCLIENT: Shelborne Hotel 1801 Collins Avenue Miami Beach FL 33139 BUSINESS .NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) 1-1271 (305) 531-2206 m NE NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional) p or Trust [Section 2-482 (c)] Fill out this section if principal is a NAME OF CHIEF OFFICER, PARTNER, OF2 BENEFICIARY: Russell W. Galbut IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST: See attached Disclosures of Interest. II. SPECIFIC LOBBY ISSUE: Certificate of Appropriateness for the partial demolition, renovation and restoration of the existing 15-story, 8-story, ~"~ and 3-story buildings, including design modifications to the ground floor, including lobby, pool deck, and cabanas, and the demolition of the existing main entrance facade and porte-cochere and construction of a new entrance and new porte-cochere, for the property located at 1801 Collins Avenue, Miami Beach, Florida 33139. Issue to be lobbied (Describe in detail): III. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED: (Pursuant to City Code Section 2-482(g) include a statement of the .extent of any business, financial, familial, professional or other relationship, giving rise to an appearance of an impropriety, with any City personnel sought to be lobbied; further, pursuant to City Code Section 2- 482(a)(4) include a statement of any contractual relationship (paid or unpaid) from 12 months preceding the commencement of service of City personnel to be lobbied.) A) FultName of IndividualITitle B) An Financial, Familial or Professional Relationship City of Miami Beach Historic Preservation Board None ~~ ~ ~ ~Jc~ ,~ ~ ~~~ ~ ~ ~~ City of Miami Beach Planning Staff None City of Miami Beach Mayor/Commissioners City of Miami Beach Committees None None ,,,~ `~ '`~~ ~ (~ ~ ~ ~ .j ,,,,, . , ` '«?~.AXL'.v~'P#WF°:WpY+q{?ry~#E#LCI+~.?. 5~ IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER " HOURLY, FLAT RATE OR OTHEF~: LOBBYIST DISCLOSURE:. (Required) $ ~ OOi t~OV .- ' , ' B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): . • (Required). $ /~~. DOO ~ - The following information must be answered: , 1) Pursuant to Miami Beach City Code Section 2-488 Entitled "Prohibited Campaign Contributions By Lobbyists On Procurement Issues": ' ^Yes ~J No: Are you iobbying on a present or pendina 'bid .for goods,. equipment or services, or on a ", present or pending award for goods, equipment or service? ` 2) Pursuant to Miami Beach .City Code 2=490 Entitled "Prohibited Campaign Contributions By .Lobbyists On Real Estate Development Issues":- • ayes 6~ No: .Are you lobbying on a pending application fora 'Development Agreement with the City or application for change of zoning map designation or change to the City's Future Land Use Map? ' 3) Pursuant'to Miami Beach City Code 2-484 (h) Any person (except those exempt from .the definition" of "lobbyist" as set forth in Section 2-48t above) who only appears as a representative of anot-for-profit corporation or entity without special compensation or reimbursement for the appearance, whether direct, or indirect; to .express support of or opposition to any item, shall register with the clerk' as Yequired by this "" section but, shall not be required to pay any,l•egistration fees.. ^Yes '~ No: Are you representing snot-for-profit corporation or entity without special compensation o_r reimbursement. ` V. SIGNATURE UNDER OATH: ' ' ON OCTOBER 1St OF EACH. YEAR, EACH .LOBBYIST .SHALL SUBMIT TO THE CITY CLERK A SIGNED '..STATEMENT. UNDER OATH, .LISTING LOBBYING EXPENDITURES, AS WELL AS COMPENSATION ' RECEIVED IN.THE CITY OF MIAMI BEACH FOR THE PRECED LENDAR YEAR. A STATEMENT SHALL BE FILED EVEN"JF THERE-:HAVE BEEN NO EXPENDITURES R CO PENSATION DURING THE REPORTING . ~ PERIOD. • Signature of L b yist -•Jonathan w. Cardello I do solemnly swear that all. of th foregoing facts` are true and correct an that I have read or am familiar with the • , • -provisions contained in Section 2- 82 of the Miami Beach City Code and all r porting requirements. . Signature of Lobbyist: ~ " Signature of Principal/Client: ' ~ Russell 1N. G ' ut, on behalf of Shelborne Associates,• Cosfello Investments, Inc., - . Shelborne Oc an Beach Hotel Corp., and Beach Group III; L` LC. V[:: LOBBYIST IDENTIFICATION:. PRINCIPAL IDENTIFICATION:.. Produced ID ^' Produced ID ~ • Form of Identification Form of Identification a o ~ ~ • Personally known (Lobbyist) ^ Personally known (Principal) ° N ~ VII. SIGNATURE AND STAMP OF NOTARY: ;,n State .of Florida, County of Miami-Dade State of Florida, County of Miami-Dade " :. ~~'~;Z m g ,,, a Sworn to "and subscribed before me „ Sworn to and subscribed. before me w~¢~ a o a ~ This ~ day of , 2010 This -day of , 2010 } W.~ ~ .~' _` ~~~;., -Signature of Pub' of ry - to of'Fforida Signature of Public Notary -State of Florida ' ~ ~ Notarisation of obbvist's ature Notarization of Princibal's, signature g o° _ "~„'l`.tw. TO BE COMPLETED BY CITY CLERK'S USE ONLY Annual Registration fee: j ]Yes [ ] Nb Amount Paid $ O .-=-`.MCR # $ ` 'Date Paid Lobbyist Registration Form received and verified by: . Ft\CLER\LOBBYIST1Lobb ist Re stration Form 32708.doc Revised 03/27/2008 _ ' ` _ (~ ~ ..- .~~ 'ti IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT RATE OR OTHER): LOBBYIST DISCLOSURE: (Required) $ o?GUE 000 --- B) . PRINCIPAL'S .DISCLOSURE (OF LOBBYIST COMPENSATION): (Required). $ ao0 t o00 - The following information must be answered: 1) Pursuant to Miami Beach City Code Section 2-488 Entitled "Prohibited Campaign Contributions By Lobbyists On Procurement Issues": DYes ~ No• Are you lobbvinq on a present or pending bid for goods equipment or services or on a present or• pending award for goods, equipment or service? 2) Pursuant to Miami .Beach City Code 2-490 Entitled' "Prohibited Campaign Contributions By Lobbyists On Real Estate Development Issues": ^Yes ~ No• Are you lobbvinq on a pending application for a Development Agreement with the City or application for change of zoning map designation or change to the City's Future Land Use Map? 3) Pursuant to Miami Beach City Code 2-484 (h) Any person (except those exempt from the definition of "lobbyist" as set forth in Section 2-481 above) who only appears as a representative of anot-for-profit corporation or entity without special compensation or reimbursement for the appearance, whether direct, or indirect, to express support of or opposition to any item, shall register with the clerk as required by this section but, shall not be required to pay any registratiorrfees.. DYes ~ No• Are you representing snot-for-profit corporation or entity without special compensation or reimbursement. V. SIGNATURE UNDER OATH: PERIOD. Signature of Lobbyist -Jonathan w. Cardello I do solemnly swear that all of the foregoing facts are true and correct and that I have read or am familiar with the provisions contained in Section 2-482 of the Miami Beach City Code and all reporting requirements. Signature of Lobbyist: Signature of Principal/Client: Russell ..Gal t, on a al elborne Associates, Costello Investments, Inc., Shelborne Ocean Beach Hotel Corp., and Beach Group tll, LLC. VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION: ^ Produced ID Form of Identification ^ Personally known (Lobbyist) VII. SIGNATURE AND STAMP OF NOTARY: ^ Produced ID Form of Identification Personally known (Principal) State of Florida, County of Miami-Dade Sworn to and subscribed before me This _ day of , 2040 Signature 'of Public Notary -State of Florida Notarization of Lobbyist's signature TO BE COMPLE' Annual Registration fee: [ Yes [ ] No Amount Paid $, Lobbyist Registration Form received and verified by: _ F:\CLER\LOBBYIST\Lobbvist Registration Form 32708.doc State of Florida, County f i - e Swor to and su ribs be ~r®~r1~e DAYAMIAGUTAR ~ i ~ day of a ~ Y `B`a's Notary Public -State of Florida _ ; . _ My Commissia~ Expires Mar 16,2011 ` e= Commission # DD 644032 Si natu of Public No =' ''of Fimd~~r+roughNada~atNocaryAsan: No riza ion of Princi CITY CLERK'S USE ONLY MCR # $ ' Date Paid n `'1 Revised 03/27/2008 Ql -.. , :~ ~a~ ~" . City of Miami Beach; 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.aov CITY CLERK office • CityClerkC~3miamibeachfl.gov - Tel: 305.673.7411,. fax: 305.673.7254 • . Jonathari W: Cardello - LOBBYISTNAME: ~ ' • I understand that no later than October 1St of each year, i must file the following forms, .pursuant to Section 2-485 of the Miami, Beach City Code, with the City Clerk's°Office #or alf active lobbyirig issues: • 1') Lobbyist Expenditure Form • - 2) 'Disclosure Form Failure to file these. forms on a timely basis will result 'in my name being. transmitted #o the Miarni-Dade` County Commission on Ethics and for code violation evaluation. Iri ad ' 'on, o e an issue I have .registered to lobby bn has been resoled, I am required to immediately notify the Cit Jerk's Offic for lobbyist withdrawal in writing. Si nature: Jonat an .Care II ~ ~_ ~ ~( 1 g de o Date: ~: • Cli°Y ®F iVilAi~il BEACH , . _ ®E!!EL®PINEi~' REVIEW ~OARD.APPLICATIOfV • ~ - DISCLOSURE ®F INTEREST ` .t - . °I C®RPORATI®N. :. `If.the property which is the subject of an application is owned or leased' by a CORPORATION, • list the principal stockholders and. the percentage of stock owried:by each. Where the .principal ~ - • offiicers or stockholders consist •of another corporation(s), trustee(s), partnership(s) or other _ ., ~ similar enfity, further disclosure shall. be .required which discloses the identity of the individual(s) - (natural. persons) having the ultimate ownership interest in the entity.* SBH INVESTORS, INC.. CORPORATION NAME NAME AND ADDRESS % OF STOCK Russel: W. Galbut 50%0 ~ ~ • • ' 2220 Biscayne Blyd. - ~ • Miami, FL-33:137 , Abraham A: Galbut, and"Nancy K. Galbut, his wife 50% 4:770 Biscayne Blvd., St.-1400 • Miami, FL 33137 `IF THERE ARE AD®ITI®NAL C®RPORATIONS, LIST OTHERS, INCLUDING CORP. NAllalE(S) AND. ~ EACH /N®IVIDUAL'S NAi1AfE, ADDRESS, OFFICE AND PERCENTAf3E OF STOCK, ON A SEPARATE PAGE. . NOTE: N®tarized,signature required ®n page ~ 6-A _ CITY ®F I~ilAlitll ~EACF~ DEVL®PI~IEfVT REVIEW ~OAR~ APPLICATION . ~ DISCLOSURE OF INTEREST .:1. CORPORATION , If the property which is the subject of an application is owned or leased by a CORPORATION; list the principal stockholders and the percentage of stock owned by each. Where the principal officers or ,stockholders consist of another corporation(s), trustee(s), partnership(s) or other . similar entity,further disclosure shall be required which discloses the identity of the individual(s) . (natural persoris) having the ultimate ownership interest in the entity.* . MAR,IRV Investment, Inc `CORPORATION NAME. ' NAME AND ADDRESS % OF STOCK . ' . Irving Cowan 100% . 3725-South Ocean Drive, Suite 718 Hollywood, FL 33019 , .. CITY ®F 11ILIAI~fII BEACH ®EVEL®PIV1ENi° REVtEVV BOARD APPLICA~°I®N . DISCLOSURE OF INTEREST . °I. C®RPORATION Ifi the property which is'the subject of an application is. owned or leased by a CORPORATION, list. the principal stockholders. and the percentage of stock owned by each. Where the principal ~ , officers or stockholders consist of another corporation(s), trustee(s)., partnership(s) or other " `"similar entity, further disciosure .shall be required which discloses the identity of the individual{s) "{natural persons) having the ultimate ownership interest in the entity.* . ~ SHELBORNE OCEAN BEACH HOTEL CORP. CORPORATION, NAME. NAME AND ADDRESS. ' ~ % OF STOCK . Russell W. Galbut 50% ' .. , . 2200 Biscayne Blvd. Miami, FL 33.137. Abraham A. Galbut, and Nancy K. Galbut, his wife. 50% . 477Q Biscayne Blvd., St. 1400` Miami, FL 33137 IF'THEREAREADDITIONAL CORPORATIONS, LIST OTHERS, INCLUDING CORD, lVANIE(S) AND .EACH INDIVIDUAL'S .NAME, a4DDRESS, OFFICE AND • PERCENTAGE OF STOCdC, ®N A SEPARATE PAGE. . - " NOTE: No#arized sigrnature .required ®n page 8 6-C ~ . - . .. . CITY OF f~IlANII ~EAC~1 DE!/EL®PIViENT REVfEW ~®AR~ APPLICA°fLOPJ , _~ DISOLOSURE OF INTEREST ~.. . .. 1: CORPO~RATI®td If the'. property which is the subject of an application is owned or leased by a CORPORATION, list the principal stockholders and the percentage of stock. owned by each. Where the principal officers::or.stockholders consist of another corporation(s), trustee(s), partnership(s) or other aimilar_entity, further~disclosure shall be required which discloses the identity of the individual(s) (natural,-persons) having the ultimate. ownership interest in the entity.* : COSTELLO INVESTMENTS, INC: CORPORATION NAME ~ ~ ; NNAME AND ADDRESS % OF STOCK: ~ ". ' Russell W. Galbut ~ 50% ,. 2200 Biscayne Blvd.. , Miami,.FL 33137 , ~ ~ ' Abraham A. Galbut, and Nancy K. Galbut, his wife 50% - 4770 Biscayne Blvd., St. 1400: 1Vliami, f:L 33137 . lF THERE ARE ADDITIONAL CORPORATIONS, L/ST OTHERS, INCLUDING CORP. IOIAME(S) .AND EACH lNDIV/DUAL'S NAME, ADDRESS, ;OFFICE AND ' PERCENTAGE OF STOCK, ON A SEPARATE PAGE. ~N®TE: Notarized signature required ®n page 8 6-® . ~ CI°~l( ®f ~/IIA~III EACF~ ®EVEL®PMERIT REVIEW ~OAR® APRLI~CATI®RI DISCLOSURE OF IfVTEREST 1. 'LIMITED L1~4B1LITY COI!llPAtdY If the prope,rty~whicfi is the subject of an application is owned or leased by a LIMITED LIABILITY . • COMPANY, list the .principal stockholders and the percentage. of stock owned by each. Where the principal officers or stockholders consist of another corporation(s), trustee(s), partnership(s) or other sii~nilar entity, further disclosure shall be required which discloses the identity of the individual(s) (nafural persons) having the ultimate ownership interest in the entity,* , BEACH GROUP III, LLC ~ ~ " LIMITED LIABILITY COMPANY NAME " 'NAM'E AND ADDRESS % OF MEMBERSHIP INTERESTS .ARC Investors, LLC ~ 50% 2200 Biscayne Blvd. Miami, FL 33137 Russell W. Galbut, as Manager 0% " ~ 2200 Biscayne .Blvd. .Miami, FL 33137 - ~ Irving Cowan, as Manager 0% " 3725 S. Ocean Drive, #707 •Hollywood, FL 33019 IMZ Investments, LLC 50% • 3725 5: Ocenn Drive,. #707 "Hollywood, FL 33019 , " . • . lF THERE ARE ADDITIONAL CORPORATIONS, LIST ®THERS, /NCLUpING CORP. NAME(S) AND EACH INDIVIDUAL'S NAME, ADDRESS, OFFICE ANI, ' PERCENTAGE OF STOCK, ON A SEPARATE PAGE. - - NOTE: Notarized signature required on page ~ 6-E . - cITY ®~ I~ni~ruLl.~E~~~ DEVEL®PNIE~1~° REVIEW DOARD APPLICATION ~, " ' ~ DISCL®SURE ®F 1NTEREST 1. LIMITED LIABILITY COMPANY If the property which is the subject of an application is owned or leased by a LIMITED LIABILITY `:COMPANY, list the principa! stockholders and'the percentag"e of stock owned by each. Where the principal officers or stockholders consist of another corporation(s), trustee(s), partnership(s) or other similar entity, further disclosure -shall be required which discloses the identity of the individuaa(s) (natural persons) having the ultimate ownership interest in the entity.' ARC INVESTORS. LLC ;LIMITED LIABILITY COMPANY NAME . ~ NAME AND ADDRESS % OF MEMBERSHIP INTERESTS Russell W. Galbut 50% 2200 Biscayne Blvd. " Miami, FL 3313.7 . Abraham A. Galbut 50% -4770 Biscayne Blvd.;. St. 1400 ..Miami, FL 33137 " lF THERE ARE ADDlT/ONAL CORPORATI®NS, LIST OTHERS; INCLUD/NG CORP. , .. ,NAME(S) AND "EACH il INDIVIDUAL'S NAME, ' ADDRESS; OFFICE AND PERCENTAGE OF STOCdC, ON A SEPARATE PAGE. NOTE: N®tarized signature required ®n page ~ ` - 6-F C6~°Y ®F IVIIA-NLI ~EAC~I ®EVELOI'IViEI~T REVIEW ~OAR® APPLICATI®N . ®LSCLOSURE OF INTEREST 1 'LIMITED.LIABILITY C®IlIIPAIdY If the property which is the subjecf of an application is owned or leased by a LIMITED LIABILITY COMPANY; list the principal stockholders and the percentage of stock owned by each. Where. the principal officers or stockholders consist of another corporation(s), trustee(s), partnership(s) ' or other similar entity, further disclosure shall be required which discloses the identity of the individual(s) (natural persons) having the ultimate ownership interest in the entity,* IMZ YNVESTMENTS, LLC LIMITED LIABILITY COMPANY NAME ' ' " NAME AND ADDRESS ,, % OF MEMBERSHIP INTERESTS ' -• Irving..Cowan 100% - 3725 South Ocean Drive, Suite 718 Hollywood; FL 33019' ,~lF THERE ARE ADDITIONAL C®RP®RATI®NS, LIST ®THERS, INCLUDING CORP.. . NAME(S) AND EACH lNDIVI®UAL'S NAME, ..ADDRESS, " ®FFICE AND PERCENTAGE Of= ST®CK, ®N A SEPARATE PAGE. ' N®TE; N®tarized signature required ®n page ~ '. 6-G . DEVEL®Pi~IEN~° RElIIEUV ~®ARD APPLI~A-fl®IV . ~ ®ISCLOSURE OF' INTEREST 1. CORPOF2ATfON ' ° _ ~ If the .property which pis the subject. of an application is owned. or leased. by a CORPORATION, list the principal stockholders and the percentage of stock owned by each.. Where the principal . officers or stockholders consist of another corporation(s), trustee(s), partnership(s) or other similar~entity, further disclosure shall be required which discloses the identity of the individual(s) (natural persons) having the-ultimate ownership interest.in fihe entity:* ~ ' SHELBORNE OCEAN BEACH HOTEL CONDOMINIUM ASSOCIATION INC.* CO:RPORAT(ON NAME ~ ` .. ~ ~ • NAME AND ADDRESS % OF STOCK _ Adam Gruber ~ 0% 1801 Collins Avenue Miami Beach, FL 33139 • Title: President .Keith Menin 0%. 1.801 Collins Avenue. Miami Beach, FL 33139 ~. Title: Vice President Rochelle Morse 0% 1801 Collins Avenue Miami. B each, FL 3 313 9 Title: Secretary *Disclosure of the individual owners of Shelbori7e Ocean Beach Hotel `Condominium ' Association, Inc. is not required because no one person or entity holds more than a total of 5% of the ownership interests in the entity. , lF THERE ARE ADDITIONAL. CORPORATIONS, LIST ®THERS, INCLUDING CORP. e NA. ME(S) .AND EACH .INDIVIDUAL'S NAME, ADDRESS, OFFICE AND • PERCENTAGE OF STOCK, ON A SEPARATE PAGE. NOTE: Notarized signature required on page S 6-H . ' CITE OF MIAMI EEACW . DEVELOPMENT REVIEW EOARD APPLICATI®N - DISCLOSURE OF INTEREST 2. TRUSTEE. " If `the property. which is~ the subject of an appiication is owned or leased by a TRUSTEE,..list the .beneficiaries of the trust -.and -the percentage 'of interest held by each. Where the beneficiaries/beneficiary consist~of corporation(s), another trust(s), partnership(s) or other similar entity., .further disclosure shall be required. which discloses the identity of the individual(s) (natural persons) having the ultimate ownership interest~in the entity.* - Not Applicable TRUST-NAME NAME, ADDRESS; AND OFFICE % OF INTEREST 3. PARTNERSHfP/LIMITED PARTNERSHIP If the property"which is the. subject' of the application is owned or leased by a PARTNERSHIP or LIMITED PARTNERSHhP, list the principals of the partriership, including general and limited partners. Where the partner(s)' consist of other .partnership(s), corporation(s), trust(s) . or other similar entity, further disclosure shall. be required which discloses the .identity of the .individual(s) (natural persons) hawing the ultimate .ownership interest in the entity* SHECBORN'E ASSOCIATES A FLORIDA GENERAL PARTNERSHIP PAR I NERSHIP NAME AND ADDRESS % OF STOCK MAR IRV Investment,. inc. 50% 3725 South Ocean Drive, #71.8 Hollywood, 'Florida. 33019 SRN Lnyogtnr~ (n~ .. , - ~ 5v% 2200 Biscayne Boulevard ,Miami; florida.33137 ~ .