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Jennifer McConney - Alton 633 Properties, LLC I el ellow 01 � AAAI BE_A City of Mia j@ qEW�MCI tbf9hetity Clerk - 1700 Convention Center Drive, Miami Beach, FL 33139 LOBW6I R6E ST�RATION 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. ` McConney Jennifer NAME OF LOBBYIST: (Last) (First) (M.1) Kobi Karp Architecture and Interior Design, Inc., 2915 Biscayne Blvd, Suite 200 Miami FL 33137 y , BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) I 305-573-1818 305-573-3766 jmcconney kobikarp.com j TELEPHONE NUMBER: FAX NUMBER: EMAIL: Please notify this office if your contact information changes:address,phone, or a-mail address. i ! L. LOBBYIST RETAINED BY: #64 Alton 633 Pro erties LLC AND SO e 15 L(�L G NAME OF PRINCIPAUCLIENT: 6200 NW 167th Street, Building B, Miami Lakes, FL 33014 BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) 305-665-9600 305-667-5041 potamkinco _gmall.com ; TELEPHONE NUMBER: FAX NUMBER:(Optional) EMAIL:(Optional) M Fill out this section if principal is a Corporation,Partnership or Trust[Section 2-482(c)] • NAME OF CHIEF OFFICER,PARTNER,OR BENEFICIARY: Alan POtamkln a • IDENTIFY ALL PERSONS HOLDING,DIRECTLY OR INDIRECTLY,A 5%OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST. o 0 II.SPECIFIC LOBBY ISSUE: Re: Property Address: 633 Alton Road, Miami Beach, FL 331391 to obtain approval to modify CD-2 Zoning Code permitted uses to include self-storage. Issue to be'lobbied(Describe in detail): iii.'CITY AGENCIES/lINIDIVIDUALS 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 Land Use and Development Cttee, Planning Board Historic Preservation Board NONE X Richard Lorber, Acting Dir Plan &Zone; Tom Mooney, Design & Preservation Mgr NON ­X City Planners- Joyce Meyers, Michael Belush NON X a I 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. Jj Sec 2-482(d)-Ariy Financial,Familial or Professional Relationship NONE f C:\Users\clerhab\AppData\Local\MicrosoftlWndows\Temporary Internet Files\Content.Outlook\83LGODDH\Lobbyist Registratign Fonnrevised 5-30-2012.doc Ewft i , r [fD iV, AA/d SAC A C H R E' r F I City of Miat@f2E@(P nfich�bfqhQ-tity Clerk 1700 Convention Center Drive, Miami Beach, FL 33139 "1" LO136TV Rt STRATION 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. McConney Jennifer NAME OF LOBBYIST: (Last) (First) (M.1) Kobi Karp Architecture and Interior Design, Inc., 2915 Biscayne Blvd, Suite 200, Miami, FL 33137 BUSINESS NAME AND ADDRESS (Number arid Street) (City) (State) (Zip Code) 305-573-1818 305-573-3766 jmcconney@kobikarp.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: Alton 633 Properties, LLC NAME OF PRINCIPAUCLIENT: 6200 NW 167th Street, Building B, Miami Lakes, FL 33014 BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) 305-665-9600 305-667-5041 potamkinco@,gmail.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: Alan Potamkin • IDENTIFY ALL PERSONS HOLDING,DIRECTLY OR INDIRECTLY,A 5%OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST: Alan Pntamkon 50% and Rahert Potamken 5n% ii.SPECIFIC LOBBY ISSUE: Re: Property Address: 633 Alton Road, Miami Beach, FL 33139, to obtain approval to modify CD-2 Zoning Code permitted uses to include self-storage. Issue to be lobbied(Describe in detail): III.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 Land Use and Development Cttee, Planning Board, Historic Preservation Board NONE X Richard Lorber, Acting Dir Plan &Zone; Tom Mooney, Design & Preservation Mgr NONE A .X City Planners -Joyce Meyers, Michael Belush 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:.commi'ssioner 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 LO :6 A OC 130 Zi6Z C:\Users\clerhat\AppData\Local\Microsoft\VVindows\Temporary Internet FilesXContent.Ouflook\83LGQDDH\Lobbyist Registratign Formrevised 5-30-2012.doc IV.; DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION'(DISCLOSE WHETHER HOURL)e,FLAT RATE OR OTHER): A) LOBBYIST DISCLOSURE:(Required) HOURLY- $350.00 B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION): HOURLY - $350.00 (REQUIRED). The following information must be answered: 1) Pursuant to Miami Beach City Code Section 2-488 Entitled"Prohibited Campaign Contributions By Lobbyists On Procu�ernent Issues": _Yes X No: Are you lobbying on a present or pending bid for goods equipment or services.or on a present or pending 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 lobbying on a pending application for a Development Agreement with the City or application for change of zoning map 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'lobbyists as set forth in Section 2-481 above) who only appears as a representative of a not-for-profit corporation or entity without special i 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. _YesXNo• Are you representing a not-for-profit corporation or entity without special compensation or reimbursement. 1 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 FOR THE PRECEDING CALENDAR YEAR. A STATEMENT SHALL BE FILED EVEN IF.THERE HAVE BEEN NO EXPENDITURES.OR COMPENSATION DURING THE REPORTING PERIOD. Signature f l- ist I do solemnly swear that all of the sego g facts are true and correc and that I ave read or.am familiar with the provisions contained in Section 2-482 of the Miami a i o a ng requirements. Signature of Lobbyist: Signature of Principal/Client: VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION: _Produced ID Produced ID Form of Identification Form of Identification R X Personally known(Lobbyist) X Personally known(Principal), VII. SIGNATURE AND STAMP OF NOTARY: ' Y State of Florida,County of Miami-Dade State of Florida',County of Miami-Dade Swo t subscribe L�+/�{ryH PlIANK t°JFF Sworn and subscri bed before`. =me This _day of '2�1 i ery uoi�c atc of Florida This day of 2012 :. . h •: My Comm Expires Apr 3.2013 i fission a EE 179221 = Signatu of P is Nota 1 ,�������� I�' r� ,�,�F.;,;,: �::;n. Signature of Public Notary-State;of Florida e Notariz on of Lobbt is Notarization of Principal's signature: TO BE COMPLETER BY CITY CLERK'S STAFF ONLY I n, a Annual Registration fee: [ ]Yes[_ ]No Amount Paid S `— MCR# 5 1 _ ate P`id Lobbyist Registration Form received and verified by: C:\Users\clerhab\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\83LGQDDH\Lobbyist Registration Formrevised 5-30-2012.doc - 3 - IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER): A) LOBBYIST DISCLOSURE:(Required) HOURLY- $350.00 B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION): HOURLY - $350.00 (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&No: Are you lobbyina on a present or pending bid for goods,equipment or services,or on a present or pending 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 lobbying on a tending application for a Development Agreement with the City or application for change of zoning map 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 2481 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 representing a not-for-profit corporation or entity without special compensation or reimbu m n . V. SIGNATURE UNDER OATH: ON FEBRUARY 28 OF EACH YEAR, EACH LOBBYIST SHALL SUBMIT TO THE CITY CLERIC A SIGNED STATEMENT UNDER OATH` LISTING LOBBYING EXPENDITURES,AS WELL AS COMPENSATION RECEIVED, IN THE CITY OF MIAMI BEACH FOR THE PREreEDING CALENDAR YEAR. A STATEMENT SHALL BE FILED EVEN IF THERE HAVE BEEN NO EXPENDITURES OR COMPENSATION DURING THE REPORTING PERIOD. Signature of 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. Signature of Lobbyist: �A k ) ) �4� Signature of Principal/Client: VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION: Produced ID Produced ID .� Form of Identification Form of Identification i Personally known(Lobbyist) Personally known(Principal) z Eit! � m VII. SIGNATURE AND STAMP OF NOTARY: a v e State of Florida,County of Miami-Dade State of Florida, County of Miami-Dade g a� Sworn to and subscribed before me Sworn subscribe Wpm me This day of , 2012 his "i� ay of d 2012 'k . _ Signature of Public Notary—State of Florida Signature of Publ' Notary—State of Florida ' Notarization of Lobbyist's signature Notarization of Principal's signature TO BE COMPLETED BY CITY CLERIC'S STAFF ONLY Annual Registration fee: [. ]Yes[ ]No -AmountPald$ MCR# Date Paid Lobbyist Registration Form received and verified by: C:1Userslclerhatl\AppData\Local\Microsoft\Windows\Temporary Internet FileslContent.Outlook183LGQDDH1Lobbyist Registration Formrevised 5-30-2012.doc i I F:\CLE1 _ oistration Form.doc Revised 04/.27/2012 city 0 Miami Beach, 1700 Convention Center Drive;Miami Beach,Florida 33139,w;vw.miamibeaeh9.20v 0 17Y CLERK Office Raj�ael E.Granado,City Clerk CityClerk @miamibeachLl.gov Tel:305.673.741 i ,Fax:305.6737254 LOBBYIST NAME: Jennifer McConney 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 names being transmitted to the Miami-Dade County Commission on Ethics and for code 'violation evaluation.' i r 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 t®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 Mibmi-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 appeal .t a Mi Wade County Commission on Ethics and Public Trust j /z,: , Signature: o Date: - 6 e " iI DDH\Lobb ist Re istration C:\Users\clerhatllAppData\LocallMicrosoftlWindowslTemporary Internet FileslContent.0ut-ook183LGQ _ y.. g. . _ . Formrevised 5-30-2012.doc _ _ .