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Michael Larkin/North Beach Flats, LLC m MIAMIBEACH 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. Larkin Michael W. NAME OF LOBBYIST: (Last) (First) (M.I) Bercow & Radell, P.A. Biscayne Blvd., Suite 850 Miami Florida 33131 BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) (305) 377-6231 (305) 377-6222 mlarkin@brzoninglaw.com TELEPHONE NUMBER: FAX NUMBER: EMAIL: I. LOBBYIST RETAINED BY: North Beach Flats, LLC NAME OF PRINCIPAL/CLIENT: North Beach Flats. LLC 321-33 84`h Street Miami Beach _ Florida 33141 BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) (305)828-4070 (305)828-9875 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: Oscar Delgado, Director of Delgado Brothers Real Estate Development, Inc., which is the Managing Member of North Beach Flats, LLC • IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST: See attached Exhibit A II. SPECIFIC LOBBY ISSUE: Extension of Time for Design Review Board File No. 20083 for property located at 321-33 84`h Street Miami Beach, Florida Issue to be lobbied (Describe in detail): III. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED: A) Full Name of Individual/Title ~ B) Any Financial, Familial or Professional Relationship None IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT RATE OR OTHERf A) LOBBYIST DISCLOSURE: (Required) $375 00 • B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required). $375 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 vresent or vending bid for goods eauivment or services or on a Qresent or vending award for goods eauivment 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 vending avvlication for a Development Agreement with the Citv or ~pvlication for change of zoning may designation or chance to the City's Future Land U~ Mau? 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 snot-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 revresenting anot-for-vrofit corvoration or entity without special comvensation or reimbursement. V. SIGNATURE UNDER OATH: ON OCTOBER 1ST 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 FOR THE PRECEDING CALENDAR YEAR. A STATEMENT SHALL BE FILED EVEN IF THERE HAVE BEEN NO EXPENDITURES OR CO PEN]~ATION DURING THE REPORTING PERIOD. ,~/I~~„ /t ~ / Signaturebf Lobbyist I do solemnly swear that all of the foregoing 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 City Code and all reporting requirements. ~ A A Signature of Lobbyist: ignature of Principal/Client: ~ I. LOBBYIST IDENTIFICATION: / 'S Produced ID ~'3 ~ Form of Identification ~ Personally known (Lobbyist) I. SIGNATURE AND STAMP OF NOTARY: ~~Li~ ate o For' a, County f ~ i- ade ~}~~ orn~~~crib ~ ~e ^^~~~ PRINCIPAL IDENTIFICATION: Produced ID Form of Identification /*1'v"Wa Personally known (Principa ~ pu Notary Public State of Florida • ~' ~`'; Isel L Delyado ' ~ tJy Commr>s~on DD678890 ~or~~ ~.xo~res 05 28(2J11 :at~ Florida, County of Mia iyor and subscrib before me iis;~day of Eti~ , 20~f~ lbl cNotary`-'State d~Florida ignature of Pu c Notary =State of Florida of Lobbyist's signature o rizatio f Principal's signature \ , FOR CLERK' E ONLY ~~~-~.~7~1 Annual Registration fee: [ ]Yes [ ] No Amount 'd R # Date Paid Lobbyist Registration Form received and verified by• Entered By: F:\CLER\$ALL\MARIA-M\Lobbyist\LOBBYIST fORM OS.doc Revised 12/08/04 .m. < r_ rfy of Miami beach, 17t}0 Corventian Center Drive, Miami Beach, flori~a 33134, wv+w.miamibeachfi,~av CIT'E' CLERK Office Tel: 345.673.741 1 ,Fax: 345.b73.7254 C>#yClerk~miarnibeachfl.gov I understand that no toter than Ottober 7 st of each year, 1 must file the following forms, 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 Form 2) Disclosure Form Failure to file these forms on a tirrely basis will result in my name being transmitted to the Ivliami-0ade County Commission on Ethics and for code violation evaluation. In addition, once on issue I have registered #o lobby on has been resolved, I am required to immediately notify the City Clerk's Office of lobbyist withdrawal in writing. ~-~' ~~ ~1~~~ ~ Signature: Date: Miscellaneous Cash Receipt -~- : - _~ _ _._ _ ~-~~- - ~~ i - -~ ril .``` ~~'s _. ~ L r . (~E pi tS i :. ;,.~ t.~.._ _1 :~._t>_i , _ii c~rr of Mu-Mi B~cH 2 9 5 3 3 0 No. ~ Cash Received of saa.,.~~ (THIS INFORMATION MUST BE COMPLETED) Director ~7 J By Account Numb r: ©(~ _ ° ~a ~ ~ Vg Preparers pp,~ ~ Dept: - EXT' Credit Card ~ Check # ~ ~ ~ ~ $ 5~ ~ ~'