Collins Ave Assoc. LLC/Variance
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city of Miami Beach Office of the City Oem
1700 Convention Center Drive, Mlarri Beach, A. 33139
Email: cltycler1<@cl.rriarri-beach.ft.us
LOBBYIST REGISTRATION FORM
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(City of Miarri Beach, City Code o,apter 2, Division 3, Sectia1 2-481)
~ Check Box if an Amendment
Revuelta
NAME OF LOBBYIST: (Last)
2560 SW 27th Avenue
BUSINESS ADDRESS: (Number and Street)
Luis
(First)
Miami
(City)
(Ml) DATE QUAUFIED AS LOBBYIST
Florida 33133
(State) (Zip Code)
(3051 995-5330
"TELEPHONE NUMBER:
(305) 995-5340
FAX NUMBER:
EMAIl:
I. LOBBYIST RETAINED BY:
Collins Avenue Associates, L.L.C.
NAME OF PRlNCIPAl/CUENT:
100 SE 2nd street
Miami
Florida 33131
(State) (Zip Codel
BUSINESS ADDRESS:
(Number and Street) (City)
(305) 995-5340
FAX NUMBER: (Optional)
EMAIL: (Optional)
(305) 995-5330
TELEPHONE NUMBER:
Fill out this section If principal Is a Corporation, Partnership or Trust [SectIon 2-482 (c)]
? NAME OF CHIEF OFFICER, PAR1NER. OR BENEFICIARY: Don Peebles
? UST ALL PERSONS HOlDING, DIRECTLY OR INOIRECTI.Y, A 5% OR MORE OWNERSHIP INTEREST IN sUcH
CORPORATION, PAR1NERSHIP OR TRUST:
U. SPEcIFIC LOBBY ISSUE:
Variance and modification application
Issue to be lobbied (Desaibe in detail):
UL CITY AGENCIES/INDMDUAlS TO BE LOBBIED:
A) FuU Name of IncIlvldual/11I:Ie B) Relationship
Jorge Gomez, Director None
.
Armando Valdes None
Tom Mooney . None
William Carey None
1.......-. .
.-
.... _Of___0f__-1--/fOUIlLY,
. FLATRAlEOR OTHER):
/I.) lOBB'fIST OlSO-OSURE:
Hour 1
8) PRINCIPAl'S o1SC\..OSURE (OF l.C)88YlST OOMPENSAllON):
v. S16NAlURE UNDER OAnt;
ON """'.... 1~ '" -'..... -'....BYISf...........-yo nt' crrv..-.......
.."'....... ....R...... USJ11IG .......... -- 10'" crrv '" -..-....
THE PRECEDING CALENDAR YEAR.
1 do -" __....... of'" _...,..re... "'" """'" "'" .....1_ ..." ""
"..-..".......-. _ "...... 2...2 of'" """, -" CIly """" """""'" "",.,
reporting req\llrementS.
Signature of Lobb'flst:
Signature of PrinclpaVOlent
c:"
~
~ IV. DISClOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISa..OSE WHE11tER HOURLY,
. FLA T RATE OR OTHER):
A) LOBBYIST DISO..OSURE:
HourI
B) PRINCIPAl'S DlSQ.OSURE (OF LOBBYIST a:JMPENSATION):
V. SIGNATURE UNDER 0A1H:
ON OCTOBER 151 OF EACH YEAR, EACH LOBBYIST SHALL SUBMIT TO THE c:rTYCLERK A SIGNED
STATEMENT UNDER OATH, USTING LOBBYING EXPENDITURES IN THE c:rTY OF MIAMI BEACH FOR
THE PRECEDING CALENDAR YEAR.
1 do solemnly swear that all of the fbregoing facts are true and correct and that 1 havereacl or am
familiar with the provisions contained in SectIon 2-482 of the Miami Beach City Code as amended, and aU
reporting requirements.
Signature of lobbyist:
tit::'"
Signature of PrIndpal/Oient
VI. LOBBYIST WENTIfI
.<! Produced 10
Form.of Identification
.<! Personally Known
vu. SIGNA11JRE AND STAMP Of NOTARY OR DEPUTY CLERK:
State of Florida, County of Miami-Dade
Swom to and subscribed before me
This ~ day of r' ,2002.
IlY P(J ~NOrAIIYIUI.
o"'~ ~(, MICHELLE 0 KOHLER
~ ~ ~ C1II".C. ......
~ <r CC78l1...
" oP IIY oorllln ClNEIC_
OFf~ OCT. 282002
Signature of Public Notary - State of Florida
Print, stamp or type name of Notary Public
FOR CLERK'S USE ONLY
Registration: N ACCEPTED ~ REJECTED DATE: '7. ~ i7 -0 'L
If rejected, slate reason:
Registration fee paid: ~Yessh[ ~OOleck MCR # 1..~4-S-\ 0
p."TA ENTRY DATE' .d~ 200' BmRED BY, ~. .tJ
I First Revision - 05/17/02
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SENT BV: BERCaw & RADELL, PAj
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3053775222;
JUN-25-02 3:58PMj
PAGE 5/5
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. rY. DJSCLClS~ OF TalHS AND AMOUNTS Of LOUYlST COMPmsAnOft (DISa.OSI; wttfTMIt HOUIlL Y.
FLA T llA ~ OR OTHER):
A) L08I1Y1STDISCL0SURE: Hourly $185.00
II) PlUNClPAl. ~ D1SC1.OSURE (OfI.OllB'l'lST CDMPEHSATlON):
Hourly $185.00
Y. SIGNAtuRE UNDUUIAnt:.
ON OCT08ER 15f OF IACH YEA.., l:AC:H LOBBYIST SHAU SUIMITTO THE CITY CURl( A SIGNI:O
STATEMENT UNDER OATH; usn_ lOI.vDfG IXPDDrTURU IItTHE CITY 0' JlUJlM1 BEACH fOR
THE PRECEDING CALENDAR YEAR.
I do solemnly swear that all of the f'oregoIng fllCt5 are t/Ue. and correct and that I ~ read or am
famlliar with the provisions tOntained In Section 2-482 of the Miami Beach Cily Code lIS amended. and an
reporting requirements-. ~
-'" Lot,.,ot ~ t - - . ,..-.
SigI1atUi'e of Principal/Client.:
VI; . UMIIIYlST m~l1ON:
i!::
c Produced 10
Fonnof IdentificatiOn
C 'Personally Known
va. SlGNATVRfAND S1'AMFOf NOTAR'I'ORPEPUTY~
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= . B;IqlIsa JIIII.. 31. :1105
. - MJaIlHatIIJ
n t.aoo-S,SUSl
State of florida, County d Miami-Dade
Sworn ta and subscribed berote-me
This 77 day of :1Z,..uvL, :200:2.
POR. CL!IlK'S USE ONLY
Regt$lBlion: l>Q ACCEPTW [] REJECTED
If rejeaed, 5li1lE: ~:
Reglstraaon tee paid: ~Yes [ J No
[ ] Cash f><J Check. MCR #
DATE: l-S" -O"L
1~5;l{<1 LD
DATA fl'tT'RY DATI!:
,
. 200-2
EHTEAeO !l':
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I Rrlt RmioiI- 05/17/02