Jose L. Gomez - Quinta Criolla, LLC lm
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City of Miami Beach Office of the City Clerk
1700 Convention Center Dhwe, Miami Be@Ch, FL 33139
LOBBYIST REGISTRATION FORM
Lobbyist means all persons employed or retained, whether paid or not, by principal who seeks to encourage the p000aga, defeat or
modification of any ond|nanne, naoo|udnn, action or dou|a|un of any commissioner- any act|nn, deo|oion, recommendation of the City
xxanage,or any city board or committee; or any acuiun, daoio|un or recommendation of any city personnel during the time period of the
ondm decision-making pmoeaa on such oct|on, decision or recommendation that foreoaaab|y 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
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lobbying activities. The term^Lobuyimmo"has specific exclusions. Please refer to Ordinance 2Uo4-343m.
Gomez Jose
NAME OF LOBBYIST: (Last) (First)
Belinson Gomez Architects, P.A. 8101 BiscaUne Blvd., # 309 A iami FL 33138
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
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/305l 559'2250 /305/ 551-1740
TELEPHONE NUMBER: FAX NUMBER: EMAIL:
Please notify this office/fyour contact information changes:address,phone, or e-mail address.
|. LOBBYIST RETAINED BY:
NAME OF PRINCIPAUCLIENT:
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20 7738/W 58*Street, # 603 Doral FL 33178
BUSINESS NAME AND ADDRESS(Number and Street) (City) (State) (Zip Code)
(786)515-8229 osca atiastuado.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: Vidal Bada Vazquez-50%and Alejandra Bada Vazquez�YQ_% r-4
IDENTIFY ALL PERSONS HOLDING,DIRECTLY OR INDIRECTLY,A 5%OR MORE OWNERSHIP INTEREST IN SUCI�CORMIRATION
PARTNERSHIP OR TRUST: See the attached. C71 C:)
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x.SPECUFUC LOBBY ISSUE: �r �
Development Approvals and ' —
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AdjUstment and Citjj Commission, if necessaUL relating to the 9=ertjj located at 1828 Bali Road, Miami Beach,--F-L
Issue to be lobbied(Describe in detail):
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III. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED: C-1
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 relati nship.
Sec 2-482(a)(4)Full Name of Individual and Contractual Relationship(Explain) YES NO
title of person to be lobbied
Planning Department and Building Department Staff None X
PB, DRB, HPB, BOA, City Commission, and Land Use None X
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Development Committee, as necessary None X
I T
Pursuant to City Code Section the extent o«any business,financial,familial o,professional
relationship,or other relationship giving rise to an appearance of an impropriety,with any current city commissioner or city personnel who is
sought touo lobbied mm identified vn the lobbyist registration form filed.
Sec 2-482(g)Any Financial,Familial or Professional Relationship
None
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER):
A) LOBBYIST DISCLOSURE:(Required): 25b• ��
B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION):
(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 X No: Are you lobbvina on a present or aendina 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 X No: Are you lobbying on a pending application for a Development Agreement with the City or application
for change of zoning map desianation 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 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 o: Are you representing 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
FM IHE ERECEDING CALENDAR YEAR, A SIATEMENT SHALL BE gbi IF THERE HAVE BEEN NO
EXPENDITURES OR
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Signature of Lobbyist
I do solemnly swear that all of the foregoing facts are true and correct nd that I have ead or am familiarlith the provisions contained
in Section 2-482 of the Miami Beach City Code a n eq ents.
Signature of Lobbyist:
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION:
Produced ID Produced ID
Form of Identification Form of Identification
LPersonally known(Lobbyist) ,Personally known(Principal)
VII. SIGNATURE AND STAMP OF NOTARY:
State of Florida,County of Miami-Dade State of Florida, County of Miami-Dade
Sworn to and subscri d bef re me Sworn and subscribed before me
This � day of fie- ,2013 T d y of 2013
Signatur f Public Notary—State ck Florida Sign, ture f lic Votary—State of Florida
Notarization of Lob®signature No rizati Principal's signature
TO BE COMPLETED L CITY CLERK'S STAFF ONLY��
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Lobbyist Reg'
SWIM
for tow.Ix"J01 I?,
I FF 010215
Revised 04/27/2012
(A of I ia i i i i (teach, 1700 Convention Center Drive, Miami Reach. Honda 33139,
CITY (IFU Office
lk'al•ael 1-:,. Granado.. City Clerk
Tel: -103.673.7411 . 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.
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 Mi mi-Dade County Commission on Ethics and Public Trust.
ignature ate
CITY OF MIAMI BEACH
DEVELOPMENT REVIEW BOARD APPLICATION
DISCLOSURE OF INTEREST
1.CORPORATION
If the property which is the subject of the application is owned or leased by a CORPORATION,list ALL of the stockholders,and
the percentage of stock owned by each. Where the stockholders consist of another corporation(s),trustee(s),partnership(s)or
other similar entity,further disclosure shall be required which discloses the identity of the individual(s)(natural persons)having
the ultimate ownership interest in the entity.*
QUINTA CRIOLLA LLC
CORPORATION NAME
NAME AND ADDRESS %OF STOCK
VIDAL BADA VAZQUEZ 50%
10773 NW 58TH STREET, # 603
FL-33178
ALEJANDRA BADA VAZQUEZ
10773 NW 58TH STREET, # 603
DORAL, FL 33178
CORPORATION NAME
NAME AND ADDRESS %OF STOCK
IF THERE ARE ADDITIONAL CORPORATIONS,LIST OTHERS,INCLUDING CORP.NAME(S)AND EACH INDIVIDUAL
STOCKHOLDER'S NAME,ADDRESS, OFFICE AND PERCENTAGE OF STOCK ON A SEPARATE PAGE.
NOTE:Notarized signature required on page 8
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