Dan Robertson- 2 Mosqueteros, LLC 9
/\Al.AAAI BEACH
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 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.
Robertson Dan
NAME OF LOBBYIST: (Last) (First) (M.I)
HR Design 1200 West Avenue, # 1103 Miami Beach FL 33139
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
305-672-5658 305-672-6809 dannahr-desian.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:
2 Mosaueteros LLC
NAME OF PRINCIPAUCLIENT:
436 Ocean Drive Miami Beach FL 33139
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
305-477-3136 305-477-7496 hialali123 aamail.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:See attached.
• IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR NDIRECTLY,A 50/ OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION,
PARTNERSHIP OR TRUST: Gl Ga4 V4
II.SPECIFIC LOBBY ISSUE:
Development Approvals and Permitting Issues, including, but not limited 0TIistoric Preservation Board, Planning and Board
bn
ofAdiustment arovals for the properties located at M Palm Avenue Miami Beach FL
Issue to be lobbied(Describe in detail):
III. CITY AGENCI ESA NDIVIDUALS 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 I NO
title of person to be lobbied
Planning Department and Building Department Staff None.
PB, DRB, HPB, BOA, FP, City Commission, LUDC, and None.
Commission Committees, as necessary None.
Pursuant to City Code Section 2-482(8)Every registrant shall be required to state the extent of any business,financial,familial or professional
relationship,or other relationship giving rise to an appearance of an impropriety,with any current city commissioner or city personnel who Is
sought to be lobbied as identified on the lobbyist registration form filed.
Sec 2-482(g)Any Financial, Familial or Professional Relationship
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Formrevised 5-30-2012.doc
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER):
A) LOBBYIST DISCLOSURE:(Required)$
B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION): $ 1
(REQUIRED).
i
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)No: Are you lobbvina on a present or uendina bid for goods.gaijinmPnt or services.or on a uresent or nendina
award for goods equipment or service?
2 Pursuant to Miami Beach City Code Section 2-490 Entitled"Prohibited Campaign Contributions By Lobbyists On Real Estate
Development Issues":
_Yes XNo: Are,you IobbyLg on a pending application for a Development Agreement with the City or application for
change of p designation or change to the City's Future Land Use Map?
3) Pursuant to Miami Beach City Code Section 2-482(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)No; Are you representina a not-for-prof�poration or entity without anPcial compensation or reimbursement.
V. SIGNATURE UNDER OATH:
ON FEBRUARY 28 OF EACH YEAR EACH LOBBYIST SHALL SUBMIT TO THE CITY CLERK A SIGNED STATEMENT UNDER
OAjH, LISTING LOBBYINQ EXPENDITUBES. AS WELL AS COMPENSATION R IVED, IN THE QIIY OE MIAMI BEACH
ME IHE IRBECEDIbIG CALENDAB YEAB, A SIAIEUEN! HALL BE V&--m IF THERE HAVE BEEN NO
EXPENDITURES OR /
Signature of Lobbyist
I do solemnly swear that a foregoin a s r rue and correct and that I have read or am familiar with the provisions contained
in Section 2-482 of the Miami e h City de re orting requirements.
Signature of Lobbyist:
Signature of Principal/Client:
Vl. LOBBYIST IDENTIFICATION: ia'b,'� PRINCIPAL IDENTIFICATION:
0
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`
Z Q C�
-'Produced ID � �``k0 2Q� �.tc �� �� �� Produced ID
1����� �4��° Form of Identification
Form of Identification y c�,
a Personally known(Lobbyist) VPersonally known(Principal) •
o c°
VII. SIGNATURE AND STAMP OF NOTARY. �° n
State of Florida, County of Miami-Dade �� `°°�,e: State of Florida, County of Miami-Dade
x-
Sworn to and subscrib4kd before me .* Sworn d subscribed before me
This day ° • 01 •• ��� This 2 day of 8 _,2013
M
M
Signature of Public tary—State-6f Florida Signature of Public Notary—State of Florida
Notarization of signature Notarization of Principal's signature c® t
TO BE COMPLETED BY CITY CLERK'S STAFF O
[AL�nr u al Registration fee: [ es[ )No Amount Paid$ MCR#3�- Date Paid
obb st Registration Form received and verified by:
J47?MA_-f f
MIA/\AIB. EACH
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov
CITY CLERK Office
Rafael E. Granado, City Clerk CityClerk @miamibeachfl.gov
Tel: 305.673.7411 , Fax: 305.673.7254
LOBBYIST NAME: Dan Robertson
I understand that no later than February 28 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, or I am no longer
lobbying on that issue or for that principal, 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
automatically suspended from lobbying until all fines are paid, unless the fine has been
appealed to the Mia i-Dade County Commission on Ethics and Public Trust.
Signature: D te:
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CITY OF MIAMI BEACH
DEVELOPMENT REVIEW BOARD APPLICATION
DISCLOSURE OF INTEREST
1.CORPORATION
If the property which is the subject of the 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 the entity).*
2 ltfosgueteros, LLC—436 Ocean Drive,Miami Beach, FL 33139
CORPORATION NAME and ADDRESS
NAME,ADDRESS,AND OFFICE %OF STOCK
1-12_Gmun LLC 011,
436 Ocean Drive
Afiami Beach, FL
Isla Grand LLC 50 710
151 Crandon.Blvd., Ste. 542
Keil Biscayne,FL
1-12 Grouu,LLC-436 Ocean Drive, Aliumi Beach, FL
CORPORATION NAME and ADDRESS
NAME,ADDRESS,AND OFFICE %OF STOCK
Ilassari Jalah 100?0 t
436 Ocean Drive
Aliarni Beach,I L
I
Isla Grand LLC- 151 Crandon Blvd., Ste. 542, Keri Biscayne,FL
CORPORATION NAME and ADDRESS
NAME,ADDRESS,AND OFFICE %OF STOCK
Carrido.Aluarndo 1001:11
151 Crandon Blud., Ste. 542
Key Biscmine,FL
IF THERE ARE ADDITIONAL CORPORATIONS, LIST OTHERS,INCLUDING CORP. NAME(S)AND EACH INDIVIDUAL'S
NAME,ADDRESS, OFFICEAND PERCENTAGE OFSTOCK, ON A SEPARATE PAGE.
NOTE.,Notarized signature requhed on page 8
6
2 MOSOUETEROS LLC 1009
436 OCEAN DRIVE
MIAMI BEACH,FL 33139 63-9451660
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DOLLARS
Continental National Bank of Miamiy<< f
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