Jeffrey Bercow - 120 Ocean Drive, LLC MIAMI BEACH f
City of Miami Beach Office of the City Clerk ;
1700 Convention Center Drive, Miami Beach, FL 33139
LOBBYIST REGISTRATION FORM 464
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 board or committee. The term specifically includes the principal as well as any employee engaged in
lobbying activities. The term"Lobbyists"has specific exclusions. Please refer to Ordinance 2004-3435.
Bercow Jeffrey
NAME OF LOBBYIST: (Last) (First) (M.I)
Bercow Radell & Fernandez, PA 200 South Biscayne Blvd., Suite 850 Florida 33131
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
(305) 374-5300 (305)377-6222 jbercow @brzoninglaw.com
TELEPHONE NUMBER: FAX NUMBER: EMAIL:
Please notify this office if your contact information changes:address,phone, or e-mail address.
I. LOBBYIST RETAINED BY:
120 Ocean Drive, LLC .
NAME OF PRINCIPAUCLIENT:
120 Ocean Drive, LLC -2675 S. Bayshore Drive, Coconut Grove, FL 33133
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
(305)416-4556 (305)377-3040 DMartin@terragroup.com
TELEPHONE NUMBER: FAX NUMBER:(Optional) EMAIL:(Optional)
Fill out this section if principal is a Corporation,Partnership or Trust[Section 2-482(c)]
• NAME OF CHIEF OFFICER,PARTNER,OR BENEFICIARY:David Martin
• IDENTIFY ALL PERSONS HOLDING,DIRECTLY OR INDIRECTLY,A 5%OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION,
PARTNERSHIP OR TRUST: See attached
n.SPECIFIC LOBBY ISSUE:
Development Approvals and Permitting Issues,including,but not limited to Historic Preservation Board and Planning Board approvals for modifications to
design and robotic/mechanical parking for the property located at 120 Ocean Drive,Miami Beach,Florida,as well as appearance before City Commission
regarding agreements.
Issue to be lobbied(Describe in detail):
III. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED:
Pursuant to City Code Section 2-482(a)(4)include the commissioner or personnel sought to be lobbied,and whether the lobbyist has entered
into any contractual relationship (paid or unpaid) with said city commissioner or personnel from 12 months preceding such
person's commencement of service with the city to the present date,stating the general nature of the subject contractual relationship.
Sec 2-482(a)(4)Full Name of Individual and Contractual Relationship(Explain) YES NO
title of person to be lobbied
Tanning Department and Building Department Staff None
B, DRB, HPB, BOA, FP, City Commission, as None
necessary*
Pursuant to City Code Section 2-482(8)Every registrant shall be required to state the extent of any blus�n s jf hq dial,fa iliat`or professional
relationship,or other relationship giving rise to an appearance of an impropriety,with any current y cdrt4missioner or city pers nnel who is
sought to be lobbied as identified on the lobbyist registration form filed.
Sec 2-482 Any Financial,Familial or Professional Relationship
None
1 a r
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR
OTHER):
A) LOBBYIST DISCLOSURE:(Required)$575.00.
B) PRINCIPAL'S DISC $URE(OF LOBBYIST COMPENSATION):
(Required). $575.00.
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 X No: Are you lobbying on a present or pending bid for aoods.egu*Urnent or services_or on a®resent or pending
award for aoods.equipment or service?
2) Pursuant to Miami Beach City Code 2-490 Entitled"Prohibited Campaign Contributions By Lobbyists On Real Estate
Development Issues":
❑Yes X No• Are you lobbying on a pending application for a Deyelopment Agreement with the City or application for
chnge 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 X No• Are `emu representing a not-for-profit corporation or entity without jogcial 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
Q6jjj, LISTING LOQBYING EMENDITURES, AS As QQM bi RECEIVED, IN THE QITY OF MIAMI BEACH
= IHE pgECEDING CALENDAB YE R, A KF FILE E"Ek' I THERE HAVE BEEN NO
EXPENDITURES Qj3.QQMPEhj§AjION DU
IL
a re of Lobby t
I do solemnly swear that all of the foreg facts ar and orrect and tha I have read or am familiar with the provisions contained
in Section 2-482 of the Miami Beach C'y de and r rti g require S.
Signature of Lobbyist:
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATION: INCIPAL IDENTIFICATION:
❑ Produced ID ❑ Produced ID
Form of Identification Form of Identification ,
Personally known(Lobbyist) Personally known
(Principal)VII. SIGNATURE AND STAMP OF
Y p�• CRISTINA D.GONZAI.EZ X
NOTARY: =�r MY COMMISSION#DD 960888 z Ej
;ate: EXPIRES:March 23,2014
Bonded Thru Notary Public Underwriters
State of Florida, County of Miami- `" - State of Florida,County of Miami-Dade $
Sworn to and subscribed before me Sworn and subscribed before men„g
This 5 - day of FE6au P% 201 T ' `day of ,26�
w
Signature of Public Notar6 Stat6lof Flo a Si6 nature bli o ary—State of Florida
Notarization of Lobb®signature Notarizat of Principal's_signature
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
Annual Registration fee: [ ]Yes[ ]No Amount Paid$ 1 MCR#. I l Dgte Pai
Lobbyist Registration Form received and verified by. t vr
r ILI
/\AIAMI BEACH
City of Miami Beach, 1700 Convention Center Drive, Miami Beach,Florida 33139,www.miamibeachfl.gov
CITY CLERK Office CityClerk @miamibeachfl.gov
Tel: 305.673.7411 , Fax: 305.673.7254
LOBBYIST NAME: Jeffrey Bercow
I understand that no later than February 28th of each -year, I must file the following
form, pursuant to Section 2-485 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 I have registered to lobby on has been resolved, I am required
to immediately notify the City Clerk's Office of lobbyist withdrawal in writing.
Pursuant to Section 2-485 (d), the City Clerk shall notify any lobbyist (or principal) who fails to
timely file a Statement and in addition to any other penalties which may be imposed as
provided in Section 2-485.1, a fine of $50.00 a day shall be assessed for all Statement(s)
filed after the due date. The City Clerk shall notify the Miami-Dade County Commission on
Ethics and Public Trust of the failure of a lobbyist (or principal) to file the Statement or pay the
assessed fines after notification.
Any lobbyist, who fails to file the required Statement by April 30th, 2012, shall be
au to,ma . ally suspended from lobbying until all fines are paid, unless the fine has been
appe le to the Mia ade County Commission on Ethics and Public Trust.
Sig ate.
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CITY OF MIAMI BEACH
DEVELOPMENT REVIEW BOARD APPLICATION
DISCLOSURE OF INTEREST
1. QRPQ TA ION
If the property which Is the subject of the application is owned or leased by a CORPORATION, list the princppal
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).*
120 Ocean Drive.-LLC
2675 South ft3 lalwre Drive,Cogenut Grove FL 33133
CORPORATION NAME and ADDRESS
NAME,ADDRESS,AND OFFICE %OF STOCK
Terra 120 Ocean Drive Investments.LLC 1 046
2665 S.Ba!&hore Dririe Suite 1020
Coconut Grove.FL 33133
Terra 120 Ocean Drive&gjstmettts LbC
2665 South B4rtshore Qdo Ste I OIQCocottut(;Mite,FL 33733
NAME,ADDRESS,AND OFFICE %OF STOCK
Terna_120 Ocean drive..LL-C _ 100016 2665 S.Baushore Drive,Suite 1020
Coconut Grove,,FL 33133
Terra 120,.Ocean Drive,LLC
2675 South Baysliore Drive,Coconut Grove FL 33133
CORPORATION NAME and ADDRESS
Pedro Martin,Managing Member
2675 S.Bayshore Drive
Coconut Grove.FL 3313,E
David Martin,Member 5046
2675 S,Baushore Drive _
Coconut Grove.FL 3,,3133
IF THERE ARE ADDITIDNAL CORPORATIONS,IlSTOTHERS,INCLUDING CORP.NAMEW AIVD EACHA=WDUAL S
NAME ADDRESS,OFFICE AND PERCENTAGE OFSTOL7C,ON A SEPARATE PAGE.
NOTE:Notarized signature requ/red on page 8
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