Ruben Gomez - 1760 Michigan, LLC M
City of Miami Beach Office of the City Clerk /IAranl' eaGi"'1 1-'L
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.
Gomez Ruben
NAME OF LOBBYIST: (Last) (First) (M.I)
AI2 Design Corp 3631 Torremolinos Avenue, Doral FL 33178
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
305-520-9242 RGomez(Irii2desian.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:
1760 Michiaan, LLC
NAME OF PRINCIPAUCLIENT:
1760 Michigan Avenue, Miami Beach, FL 33139
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
786-208-2113 tmaena69(aIaol.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: Todd Glaser,Manager of Todd Glaser Management,LLC,the-Manager of
1760 Michigan,LLC
• IDENTIFY ALL PERSONS HOLDING,DIRECTLY OR INDIRECTLY,A 5%OR MORE OWNERSHIP INTEREST IN SUCH,CORATION,
PARTNERSHIP OR TRUST:Todd Glaser 40%,Brad Miller 60%
i.SPECIFIC LOBBY ISSUE: r_
Development Approvals and Permitting Issues, including, but not limited to Historic Preservation Board, Planning Board,._Board
of Adjustment, Land Use Development Committee, and City Commission, if necessary, relating to the property looccated"at 1760
Michiaan Avenue,Miami Beach.Florida. ••
Issue to be lobbied(Describe in detail):
Ill. 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
Planning Staff City Commission, Development None. X
Boards, Land Use Development Committee None. X
•
and Commission as necessary None. X
Pursuant to City Code Section 2-482(g)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
None.
None.
None.
Iv. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER):
A) LOBBYIST DISCLOSURE:(Required) $ `O/hour
B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION): (REQUIRED). $ 1CO/hour
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 XNo: Are you lobbying on a present or pendina bid for aoods.eauioment or services.or on a present or pending
_
award for aoods.eauipment 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 Iobbvina on a oendina application for a Development Aareement with the City or application for
chanae of zonina map designation or chanae to the City's Future Land Use Mao?
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 XNo: Are you reoresentina a not-for-profit corporation or entity without special 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
OATH. LISTING LOBBYING EXPENDITURES. AS WELL AS COMPENSATION RECEIVED. IN THE CITY OF MIAMI BEACH
EXpENDITURES OR COMPENSATION DURING THE REPORT ►;G PERI 0,1
A,- .
Signature G obb''st ir
I do solemnly swear that all of the for=%oing 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 1f ty Code an II reporting requirements.
Signature of Lobbyist: J�
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION: • --. —r o �`
' I
.Kim..ai._a,.. 1.,,i, °6 C 'i
Pr uced ID ° `,,a`5,.,,.k =��`
� Produced ID 1_I!t
Form of Identification } «_°:(1);s Form of Identification =°D °a• ,mom:
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��*a�•;m�� co m
_Personally known(Lobbyist) 4 Personally known(Principal) a c o
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VII. SIGNATURE AND STAMP OF NOTARY: 1;a n n d o y 3 n
d C C ' t0 N T Cr C
State of Florida, County of Miami-Dade i g H Q < State of Florida, County of Miami-Dade a ' . o
%Sworn to nd subscribed efor me o x ° Sworn and subscribe before me 4 T a d r w
This 0 day of I , 2015 ; * H o , This ,�8ay of _ , 2015 • --� o o
1 7 T D co 0 r a w O T Z .
z -t0 Z /! d N CO 0
Signature of Publi 'Notary—State of Florida A p s ignature of P,+1fF7 otary—State of Florida P cod f,
Notarization of Lobbyist's signature A o o k.otarization of :.r 1 • ' signature a--z-- ., Y..i' ,
G .., -• N
TO BE COMPLETED=— -'-''CL RK'S STAFF ONLY
Annual Ragictratinn fee. [ I Yec[ ]Nn Amnunt Paid �Q MCl/# Lt0 /1 Data Paid 1g-
Lobbyist Registration Form received and verified by: CV __ ��
Lc1 51 4 33 -0 403 6� `0, l'C
--------
, .
, M I AM I BEACH
City of Miami Beach, 1700 Convention Center Drive; Miami Beach, Florida 33139, www.miamibeachtl.gov
CITY CLERK Office
Rafael E. Granado. City Clerk CityClerk@miamibeachfl.gov
Tel:305.673.741 1 , Fax: 305.673.7254
LOBBYIST NAME: Ruben Gomez
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
Y Y 9
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 th Miami-Da e County Commission on Ethics and Public Trust.
•
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Signature: Date:
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City of Miami Beach-Florida
Finance Department
1 City Hall
1509713-1 04/07/2015 BR1 T134
Tue Apr07,2015 09:29AM Trans#9-9
9 $500.00 MCRCLERK - MCR-City Clerk
* MCR#: 403415
1 ITEM(S): TOTAL: $500.00
Check (0000001305) PAID $500.00
Have a nice day!
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1760 MICHIGAN,LLC 1 0 7 2
CITY OF MIAMI BEACH 4/6/2015
Date Type Reference Original Amt. Balance Due Discount Payment
4/6/2015 Bill 04062015 1,050.00 1,050.00 1,050.00
Check Amount 1,050.00
BRAD MILLER LOBBYIST REGISTRATION 1,050.00
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