Jose L. Gomez - AC 1700 Alton Owner LLCr
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City of Miami Beach Office of the City Clerk
1700 Convention Center Drive, Miami Beach, FL 33139 c.,• -
LOBBYIST REGISTRATION FORM
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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 Jose L.
NAME OF LOBBYIST: (Last) (First) (M.I)
Beilinson Gomez Architects PA 8101 Biscayne Blvd., Suite 309-310, Miami, FL 33138
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
(305) 559-1250 (305) 551-1740 ia(beilinsonarchitectspa.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:
Adam Verner
NAME OF PRINCIPAL/CLIENT:
AC 1700 Alton Owner LLC 320 5th Ave., Unit 800, New York NY 10001
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
(212) 982-2022 acs isprincjhor.use!vartners.corn.
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 the Attached.
• IDENTIFY ALL PERSONS HOLDING,DIRECTLY OR INDIRECTLY,A 5%OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION,
PARTNERSHIP OR TRUST:
II.SPECIFIC LOBBY ISSUE:
Development Approvals and Permitting Issues, including, but not limited to the Historic Preservation Board, Design Review
Board, Planning Board, Board of Adjustment, Land Use Development Committee, City Commission, and any City Workshops or
committees. if necessaru. relatina to the orovertu located at 1700 Alton Road. Miami Beach. Florida.
Issue to be lobbied(Describe in detail):
lll. 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
Staff for the Planning Department, Building Department, None. X
Public Works and City Administration, PB, HPB, BOA, None. X
City Commission, and Mayor 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_
Non a
C:\Users\clerhatl\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\83LGQDDH\Lobbyist Registration
Form revised 5-30-2012.doc
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER):
A) LOBBYIST DISCLOSURE:(Required)$50'0%4OLL ...
B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION): $2 -o 4 ociti OUft
(REQUIRED).
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 lobbvina on a present or oendina bid for aoods.eauiAment or services.or on a present or bending
award for aoods.eauiAment 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 lobbvina on a Aendina application for a Development Aareement with the City or application for
chanae of zonina man desianation 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 X No,: Are you representina 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 Ti THE CITY CLERK A SIGNED STATEMENT UNDER
OATH. LISTING LOBBYING EXPENDITURES. AS WELL AS COMPEN :,TION RECEIVED. IN THE CITY OF MIAMI BEACH
ME THE PRECEDING CALENDAR YEAR. A STAT u NT 'L FILED EVEN IF THERE HAVE BEEN NO
EXPENDITURES OR • • ■ . •. . : ■ . : ,l•1 i1f to - : •i
AlMi
Signatu - of Lobbyist
I do solemnly swear that all of the fore..•-: cts a - true and •orrect and that I ave read or am familiar with the provisions contained
in Section 2-482 of the • I :ea • -ity C. d all reporting equirements.
w
Signature of Lobb • t:
Signature of Pr' cipal/Client: ,!�r
0,112,'I,',,
VI. LOBB T IDENTI (CATION: E Q PRINCIPAL IDENTIFICATION: ,,Ot 0 E. N O V''.'.
Produced ID . o 1 o , Produced ID dp.01N0614599T
�' . QUALIFIED 1N
Form of Identification ,� Form of Identification: n YORK COUNTY;
y 1 i COMM.EXP. r Y
XPersonal) known(Lobbyist) — a ° • a 0311512018 z.
Personally ( ) �: Personally known(Principal) %,,,-......pVB`,G.O.0,•
i 1 g 1.i VII. SIGNATURE AND STAMP OF NOTARY: 3 i '.,F O F ti v.
�' NGwYorlc Aitiw Yur
State of Florida, County of Miami-Dade State of Hortda, County of Miami Dade
��serc� Sworn a d subscrib d of re me
Sworn to and subscribed before me ,,,.,O'WI
' y tt'r. r�
This ‘14.1" day of , 2015 This 30 day of ,2015.troS 6i:
Signatu of Public Notary—State f Florida Signature of Public Notary—State of F)aria I.1P.wV0rV-
Notarization of Lobbyist's signature Notarization of Principal's,signature
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY Annual Registration fee: [ ]Yes[ No Amount Paid$ MCR# qbg 52C) Date Paid l yg/8 Al -=----------Lobbyist Registration Form recei ed and verified by
a � .. g
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachll.gov
CITY CLERK Office
Rafael E. Granado, City Clerk CityClerk;cumiamibeachfl.gov
Tel: 305.673.7411 , Fax: 305.673.7254
LOBBYIST NAME: Jose L. 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
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 Miami-Dade • ounty Commission on Ethics and Public Trust.
Signature: l ate:
C:\Users\clerhatl\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\83LGQDDH\Lobbyist Registration
Formrevised 5-30-2012.doc
AC 1700 Alton Owner LLC
1700 Alton Road Investor List
Name $ % Address
Michael Or love 5750,000 8.8%
Mickey Gottlieb S150,000 1.8%
Eric Harvitt S200,000 2.4%
Stuart Hescheles $75,000 0.9%
Craig Hescheles $75,000 0.9%
Todd Cather 5500,000 5.9%
Ed Berro $500,000 5.9%
Adam Verner $512,500 6.0%
Ralph Bernstein S500,000 5.9%
Aaron Speisman $450,000 5.3%
Scott Hoffinan S100,000 1.2%
Steven Bleier $100,000 1.2%
Russ Di mini S100,000 1.2%
Zach Papadakis 5275,000 3.2%
David Schamus $100,000 1.2%
Ross Schuback 5100,000 1.2%
Jacob Kohn $850,000 10.0%
Leon Goldstein $500,000 5.9%
Harold Schertz $200.000 2.4%
Motti Hellman 5125,000 1.5%
Steve Rhodes $300,000 3.5%
Chaim Cahane 5662.500 7.8%
Kris Torkan S1,000,000 11.8%
Yoeli Klein S275,000 3.2%
Michael Werner 5100,000 1.2%
Total $8,500,000 100.0%
Miscellaneous Cash Receipt z : N r 2 0i. 001 g.
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Preparer: ' 1,-/C-', Dept: 1'1-(=./ '' 1 (/'\--EXT:, ....--1(1f6" l'
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City of Miami Beach-Florida
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ITEM( : AL: $1050.00
Check (001059) PAID $1050.00
Have a nice day