Charles H. Benson - Surfstyle @ 1155 Collins Ave gf avt p7e
AA I AAA I BEACH \
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City of Miami Beach Office of the City Clerk
1700 Convention Center Drive, Miami Beech, FL 33139
LOBBYIST REGISTRATION FORM
Lobbyist means of persons employed or retained, whether paid carrot, by a principal oho seeks to age the passage, defeat or modification of
any ordinance, resolution, ac or decision of any commissioner: any action, decision, recommend at m of the City Manager car any city board or
committee; or any action, decision or recommendation of any city person during the time e period of the entire . -making process can such
action. decision or reoorr nendation that foresetably left be head or reviewed by the city c mmssbn. or a city board or conunittee. The term
specifically includes the principal as wel as any erne engaged in touring activities. The term "Lobbyists has sperritio exclusions. Please
refer to Ordinance 2004-3435.
Benson Charles H.
NAME OF LOBBYIST: (Last) (Filet) (NU)
Charles H. Benson & Associates, Architects, P.A., 1665 Washington Avenue, 2 Floor Miami Beach, FL
BUSINESS NAME AND ADDRESS (Number and .met) (C84 (State) ( )
0 (305) 532 -6161/ C (786) 246 -8180 / F (305) 532 -6151 carkitect3 @aol.com
TELEPHONE NUMBER: FAX NUMBER: EMAIL:
Please notify this office if your contact information changes: address, phone, or eernaft address.
L LOBBYIST RETAINED BY:
E.D.Y. Inc., a Florida Corporation
NAME OF PRINtPAL LIENT:
Surfstyle 4100 N 28 Terrace, Hollywood FL 33021
BUSINESS NAME AND CRESS (Number and Street) (City) (State) (2 )
T 011 FAX NUMBS (Optional) EMAIL: (Optional)
Fill out this section it principal is a Corporation, Partnership or Trust [Section 2.482 (c)J
• NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY:
Yossi Lipkin
• IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR IIRECTLY, A S% OR MORE OWNERSHIP INTEREST IN
SUCH CORPORATION, PARTNERSHIP OR TRUST: Yossi Lipkin, Elijah Levy, Doron Malinasky
lkgc)F o os Project Name /Address: Surfstvle (a,1155 Collins Avenue
Re=hear g of prevtou approve" ew 3 story retail building with parking spaces and re- hearing of previously BOA approved sign .
Re- hearing to be heard by HPB and BOA.
(Describe In i t
m . a I } `GE IgtP /1 3 'I A ' z
E � !; Pursuant to City Code Sec 'ion 2.48240) include
3v. ���.:��.�. � 4 ��.<.«�<.� a ...v�.�.�,� .� .�e�.. «.e.� .�
a went ot the extent ot any irneaa, tI nar al,. famail 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 Victual relationship (paid or unpaid) from 12 months preceding said City
personnel' comntencennent of Strike with the City to the present date, stating the general nature of the subject
contractual ration.
A) Full Name of rndivtdual/Titie B
� Any Financial, Familial �' Professional Relationship
Historic Preservation Board members None
Board Adjustment board members None
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N. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT
RATE OR OTHER):
A) LOBBYIST DISCLOSURE: (Required)
8) PRINCIPAL'S DISCLOS RE (OFBYiST COMPENSATION):
(Required). 1 QC7.
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:
0 Yes 13 No: Are you lobbying on a present or pending bid for hoods. eguipment 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 ":
0 Yes C No: Are you lobbying 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 a not -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 registration fees.
Yes ERNo: Are you representing a not-for-profit corporation or entity without special compensation or
reimbursement. .
V. SIGNATURE. UNDER OATH:
ON FEBRUARY 28th 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 PRECEDING CALENDAR YEAR. A STATEMENT SHALL,
BE FILED EVEN IF THERE HAVE BEEN NO EXPENDITURES O 7MP SAT DURING THE REPORTING
PERIOD.
Signature of Lobbyist
I do solemnly swear that all of the foregoi %cam • re e nd correct and that i have read or am familiar with the
provisions contained in Section 2-482 of y e C' Code and all reporting requirements.
Signature of Lobbyist
Signature of Principal /Client: igi;irmAgir •
VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION:
❑ Produced ID 0 Produced ID
Form of identification Form of Identification
N U
-, ri<3 Adrlana 0 692
� N � � Personally known (Lobbyist) Sd Personally known (Principal) o``�►Y �� � •
• rit• ,., `�; • COMMISSION
z e ` < WIRES.. AUG.09,20t4
$ VII. SIGNATURE AND STAMP OF NOTARY: = 'a� -•
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A State of Florida, County of Miami -Dade State of Florida, County of Miami -Dade n�M•
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-- g :w r Swom to and subscribed before me Swom and subscribed before me
o r This :! of e•k.Att a 2010 This 21srda of OcIbloer, 2010
• gi/m7Q9-5,„RA,
It. Z Signature of Public V otary — Sta \. of Florida Signa ' o Public Notary — State of Florida
t � Notarization of Lo • byist's signature Notari ation of Principal's signature
Yo s r
TO BE COMPLETED 8 J ITY CLERK'S STAFF ONLY A
Annual Registration fee. I Yes [ I No Amount 1 ' S te• L. ) MCR # ;, Date Paid . 15 ,
Lobbyist Registration Form received and verified by '
FACLER‘SALL‘aFORMS�It088YIST F0RMStLcbbyist Regi won'.• * ► , .' a � Revised 05/05 /2010
'BEACH
City of Miami i s.. h,1700 Convention Center Drive, Miami Beach, Florida 33139, www.raiannibeacki.gov
CITY CLERK Office Ciiyaet rniamibeachiLe v
Tel: 305.6 3.7411 , Fax: 305.673.7254
LOBBYIST NAME: Charles H. Benson
1 understand that no later than ,February 28th of each year, 1 must file the following
form, pursuant to Section 2485 of the Miami Beach City Code, with the City Clerk's
Office for all active lobbying issues.
1) Lobbyist Expenditure and Compensation Form
Failure to file these forms on a timely basis will result in my name being transmitted to the
Miami -Dade County Commission on Ethics and for code violation evaluation.
In addition, once an issue 1 have registered to lobby on has been resolved, I am required
to immediately notify the City Clerk's Office of hobbyist withdrawal in writing.
Signature: Date:
Y Mis el aneous i cei it
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