Jose Gomez - Shay Kostiner ' � I BEACH
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City of Miami Beach Office of the City Clerk
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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.
Gomez Jose
NAME OF LOBBYIST: (Last) (First) (M.I)
Beilinson Gomez Architects 8101 Biscayne Boulevard, Suite 309-310, Miami FL 33138
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
305-559-1250 305-551-1740 igabeilinsonarchitectspa.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:
Shay Kostiner
NAME OF PRINCIPAL/CLIENT:
1521 Alton Rd, #304 Miami 6€4 Cl\ FL 33139
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
305-531-6750 sk4inc(r,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: N/A
- ri •
• IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY,A 5%OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION,
PARTNERSHIP OR TRUST: N/A
II.SPECIFIC LOBBY ISSUE: -�
Development Approvals and Permitting Issues relating to the property located at 44 Star Island Drive, Miami Beach, Florida.
Issue to be lobbied(Describe in detail):
Ill. 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
Planning, Building and Public Works staff None. X
PB, DRB, BOA, City Commission, and Land Use None. X
Development Committee, as necessary
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
None.
None.
None.
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER):
A) LOBBYIST DISCL SURE:(Required)
2So%oo I-10 u e�
B) PRINCIPAL' DISCLOSURE(OF LOBBYIST COMPENSATION):
(REQUIRED). 4.2 ,CYC f to(...l
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 XNo: Are you lobbvina on a present or oendina bid for aoods.eauipment 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 lobbvina on a pending application for a Development Aareement with the City or application for
chanae of zoning map desia,_.'•.I • I•.I•, . Ci '. - •• .- ►4
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.
—YesXNo: 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 RECEI D. IN THE CITY OF MIAMI BEACH
ma - . - _-
EXPENDITURES OR COMPENSATION DURING THE REPORTING PERIO li 1
Signature of Lobbyi
I do solemnly swear that all of the foregoing facts are true -1• orrec .. that I have read or a Ti familiar with the provisions contained
in Section 2-482 of the Miami Beach City Code and . eporting -q b. e el .
Signature of Lobbyist: _i
/A
Signature of Principal/Client: - in
rIlli
VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION:
Produced ID Produced ID ,D iLi vted-f L-r 62-IAQ
Form of Identification Form of Identification
Personally known(Lobbyist) Personally known(Principal)
VII. SIGNATURE AND STAMP OF NOTARY:
'' �\••;9ONION090• 'i
State of Florida, County of Miami-Dade =a sIot'stAew o' State of Florida, County of Miami-Dade
Sworn to and subscribed before me F.,� ; S3HIdX3 Z_ Sw• and subscribed before me
This a day of3.)ll ,2016 =2'•••2 e3ew N .:C .fi I day of beau-4e,— , 2014
-.9CLI.D_.,k1 -,,,/0 -...Yli....,-;k,; /)/ ,
Signatur of Public Notary-St of Florida ,,,"'������Sign- (-1•f Public Notary-State of Florida
Notarization of Lobbyist's 'gnature No ri "tion of Principal's signature
- OMPLETED BY CITY CLERK'S STAFF ONLY
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City of Miami Beach, 1700 Convention Center Drive, Miami Reach, Florida 33139, www.miamibeachfl.gov
CITY CLERK Office
Rafael E. Granado, City Clerk
CityClerk rniamibeachfl.g
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Tel: 305.673.7411 , Fax:305.673.7254
LOBBYIST NAME: Jose 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.
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 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 fi ,e has been appealed to the Miami-Dade County Commission on
lic Trust.
1\51201S—
Si'nature: Date:
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City of Miami Beach-Florida
El narice Department
1 City Hall
1505520-1 02/24/2015 BR1 T121
Tue Feb24,2015 03:19PM Trans#19-19
19 $350.00 MCRCLERK - MCR-City Clerk
MCR#: 402702
1 ITEM(S): TOTAL: $350.00
Check (0139) PAID $350 00
Have a nice day!
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