Dan Robertson - 2 Mosqueteros, LLC /\A I A M�I B E AC'
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.
Robertson Dan
NAME OF LOBBYIST: (Last) (First) (M.1)
_HR Design 1200 West Avenue, # 1103 Miami Beach FL 33139
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
305-672-5658 305-672-6809 dan(a�hr-design.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:
2 Mosaueteros LLC
NAME OF PRINCIPAL/CLIENT:
436 Ocean Drive Miami Beach FL 33139
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
305-477-3136 305-477-7496 hialali123agmail.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:See attached.
• IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR NDIRECTLY,A 50/ OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION,
PARTNERSHIP OR TRUST: Gu SG
ii.SPECIFIC LOBBY ISSUE:
Development Approvals and Permitting Issues, including, but not limited to TIistoric Preservation Board, Planning and Board
oPAdiustment aoorovals for the nronerties located at M Palm Avenue Miami Beach FL
Issue to be lobbied(Describe in detail):
III. CITY AGENCIESANDIVIDUALS 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,st ting 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
Planning Department and Building Department Staff None.
PB, DRB, HPB, BOA, FP, City Commission, LUDC, and None.
Commission Committees, as necessary None.
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
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I
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER):
A) LOBBYIST DISCLOSURE:(Required)$
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)Mo• Are you lobbyjna on a present or pending bid for good eguopment nr SPrvirac_nr nn a present or pending
award for goods,eauipment or service?
2) Pursuant to Miami Beach City Code Section 2-490 Entitled"Prohibited Campaign Contributions By Lobbyists On Real Estate
Development Issues":
_Yes)NO: 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 1&22
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)Now Are you representing as nprofit 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
OAJH. LISTIbIG LOBBYINQ gXPENDITURES. Aaj WELL AS QOMPENSATIQN R IVE12, IN THE CITY OF MIAMI BEACH
EQH IHE PRECEDING CALENDAR YEAR, A STAIEUENT-SHALL B IHERE IJAVE gEEbj bIQ
EXPENDITURES OR
Signature of Lobbyist
I do solemnly swear that a foregoin a s treporting rue and correct and that I have read or am familiar with the provisions contained
in Section 2-482 of the Miami ea h City de requirements.
Signature of Lobbyist:
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION:
Produced ID �� �.tc � �� Produced ID
J���`� �4�_° Form of Identification
Form of Identification �v � �y �, c�
VPersonally •
Personally known(Lobbyist) known(Principal)al P )
VII. SIGNATURE AND STAMP OF %% c>°c�, •
State of Florida, County of Miami-Dade *°•�a State of Florida, County of Miami-Dade
Sworn to and subscri d before me o,p Sworn d subscribed before me >
This day 0 -y `• °; This day of B 2013 n�
' '„5;;;; m
M
Signature of Public tary—State-6f Florida Signature of Public Notary—State of Florida
Notarization of signature Notarization of Erincil2al'5 signature as t
TO BE COMPLETED BY CITY CLERK'S STAFF O
Annual Registration fee: [ es[ )No Amount Paid$ MCR# Date Paid
Lobbyist Reg Form received and verified b fLr
ct,-1 FV7 OCA71 1 7
MlAt\Al BEACH
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov
CITY CLERK Office
Rafael E. Granado, City Clerk CityClerk @miamibeachfl.gov
Tel:305.673.7411 , Fax: 305.673.7254
LOBBYIST NAME: Dan Robertson
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.] 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
Statements filed after the due date. The City Clerk shall notify the Miami-Dade
( ) Y
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 Mia i-Dade County Commission on Ethics and Public Trust.
Signature: D te:
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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 the principal
stockholders and the percentage of stock owned by each. Where the principal officers or 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).*
2 Alosaueteros,LLC—436 Ocean Drive,Miami Beach, I%L 33139
CORPORATION NAME and ADDRESS
NAME,ADDRESS,AND OFFICE %OF STOCK
i
112 Gr'ouo LLC 509E;
436 Ocean Drive
Afiami Beach FL
Isla Grand LLC 50 0/10
151 Cmridon.Blvd., Ste. 542
Kcrl Discarpne,FL
1-12 Grouv,LLC-436 Ocean Drive, Aliund Beacl r, FL
CORPORATION NAME and ADDRESS
NAME,ADDRESS,AND OFFICE %OF STOCK
Ilassart Jalali 100?0 �
436 Ocea►r Drive
Aliarn Beacli.IL
I
Isla Grand LLC- 151 Craridari Blvd., Ste. 542, Ketl Biscatlne,FL
CORPORATION NAME and ADDRESS
NAME,ADDRESS,AND OFFICE %OF STOCK
Carrillo Alvarado 10096
151 Crandon Blvd, Ste. 542
Ker 131 iscnime, F-L
IF THERE ARE ADDITIONAL CORPORATIONS, L157-OTHERS,INCLUDING CORP. NAME(S)AND EACH INDIVIDUAL'S
NAME,ADDRESS, OFFICEAND PERCENTAGE OFSTOCK, ONASEPARATEPAGE.
NOTE:Notarized signature required on page B
6
'
2 MOSQUETEROS LLC 1009
436 OCEAN DRIVE
MIAMI BEACH,FL 33139 63-945/660
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