Loading...
Jose L. Gomez - Williams-Sonoma, Inc. ', 4, 110R1 Mc,W tier Arveiko._ . i 0 MIAMI tj :. City of Miami Beach Office of the City Clerk 'R 1700 Convention Center Drive, Miami Beach, FL 33139 2a6 APR —5 Ati 6: 5 6 LOBBYIST REGISTRATION FORM Lobbyist means all persons employed or retained, whether paid or not, by a principal who seeks to enc'o,u;ra`e,�the ass' e,.defeat.or Y P P Y p P 9 P 9 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 L. NAME OF LOBBYIST: (Last) (First) (M.I) Beilinson Gomez Architects P.A., 8101 Biscayne Boulevard, Suite 309, Miami, FL 33138-4664 BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) (305) 559-1250 (305) 551-1740 ia(beilinsonarchitectspa.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: Joan Fitzgerald Hill, VP Real Estate for Williams Sonoma, Inc. NAME OF PRINCIPAUCLIENT: Williams-Sonoma, Inc., 3250 Van Ness Avenue, San Francisco, CA 94109 BUSINESS NAME AND ADUKESS (Number and Street) (City) (State) (Lip Code) 415-421-7900 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:Publically traded on the NYSE as WSM. • IDENTIFY ALL PERSONS HO DING,RIRECTLY R I DIRECTLY,A 5%OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST: is 0-'0\VA`l II.SPECIFIC LOBBY ISSUE: f Dev_elopmerit_Approvals and Permitting Issues, including, but not limited to the Historic Preservation Board, Design Review Board, Planning Board, Board of Adjustment, Land Use Development Committee, City Commission,_and any City Workshops or Committees, if necessary, relating to the provertu located at 16.9. 1 Michigan A_.venue, 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 Staff for the Planning Department, Building Department, None. X Public Works and City administration, PB, HPB, BOA, None. X City Commission, and Mayor as necessary 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 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. C:\Users\clerhatl\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\83LGQDDH\Lobbyist Registration P. Formrevised 5-30-2012.doc ,4 IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER): A) LOBBYIST DISCLOSURE:(Required)$ 950 1hr- B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION): $ ✓) I K1r• (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 XNo: Are you lobbvina on a present or oendina bid for aoods.eauipment or services.or on a present or pending award for aoods.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 XNo: Are you lobbvina on a pendina application for a Development Agreement with the City or application for _ chanae of zonina map desianation or chanae to the City's Future Land Use Mao? 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 No: Are you reoresentina 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 COMP* SATION RECEIVED. IN THE CITY OF MIAMI BEACH �,B THE PRECEDING CALENDAR YEAR. A STATE T ALL BE FILED EVEN IF THERE HAVE BEEN NO EXPENDITURES OR COMPENSATION DURING THE R TI _ •l )1 I Sign. ure of Lobbyist I do solemnly swear that all of the foregoing facts are ue an• correct an. that I hav: read or am familiar with the provisions contained in Section 2-482 of the Miami Beach City Code and all r orti • requ. - = ts. Signature of Lobbyist: .i '..,,, Signature of Principal/Client: . 4 VI. LOBBYIST IDENTIFICATION: , ��,,,,,,, P', NCIPAL IDENTIFICATION: SAP t.+ % /�� Produced ID 001 Z..ProducedlD V �Iv�VI I)vvv m. Form of Identification '•qbo •'..�;.•' Form of Identification Personally known(Lobbyist) n;fz- Personally known(Principal) 3 0 VII. SIGNATURE AND STAMP OF NOTARY: H 3 Q • O K � State of Florida, County of Miami-Dade , �,,-Sta = of Florida, County of Miami-Dade Sworn+" -- ubscribed before me ..�A m Sworn -•• subscribed before me This '9Td: of,ii,&, I , 5r"i b o °: s a This •- of ,2015 OM A / ' cn CA T " Sig<a u - . " bli• o ary—State of Florida t w •ignature of Public Notary—St. - of Florida No .riza • of Lobbyist's signature 'otarization of Principal's signa . e TO BE COMPLETED BY CITY CLERK'S STAFF ONLY Annual Registration fee: [ ]Yes[� No Amount Paid$ 3S0.v" MCR# L,Qa1 I 10 to Date Paid 0i(_cS-1 b Lobbyist Registration Form received and verified b O V Y 9 Y' � 'ttib CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT CIVIL CODE§ 1189 A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached,and not the truthfulness,accuracy,or validity of that document. State of California County()LSO') � C5(A ) On MKdi a, ;--ol (o before me, LaA,crmelhereS(Ervinin�AboAtii �(�l,(%il Date Here Insert Name n Tit/ of the Qer i personally appeared jou,n � Name of Slignerg who proved to me on the basis of satisfactory evidence to be the personV whose name( is/ape subscribed to the within instrument and acknowledged to me that l / he/tp(ey executed the same in hi'/her/thOr authorized capacity(i ),and that b lyts/her/th f r signature(0on the instrument the person(,, or the entity upon behalf of which the person acted, executed the instrument. I Y P certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. LAURIE THERESA BROWN - Commission# 1990296 WITNESS my hand and official seal. z; ,� Notary Public-California Z• z ''' San Francisco County It Comm;-x-ir's Sep 3, 206 • Signatur /t 4 Signature of Notary Public Place Notary Seal Above OPTIONAL Though this section is optional, completing this information can deter alteration of the document or fraudulent reattachment of this form to an unintended document. Descriptio - Attached Document Title or Type of Di •_ a ent: Document Date: Number of Pages: -'•ner(s) Other Than Named Above: Capacity(ies) Claimed by Signer(s) Signer's Name: Signer's Name: ❑Corporate Officer — Title(s): _ • •- •orate Officer — Title(s): ❑Partner — ❑Limited ❑General ❑Partner • Limited ❑General ❑Individual ❑Attorney in Fact ❑ Individual Attorney in Fact ❑Trustee ❑Guardian or Conservator ❑Trustee ❑G •ian or Conservator ❑Other: ❑ Other: Signer Is Representing: Signer Is Representing: :1' &'-.v•d-a4�.✓G'�r:✓:�4�4C✓G��� 4�4�-.:7:� G�4'yF�G't7QL-.•�$$ •�•�•r/•�':�� G�6�✓4�✓.4�•.•J:•6":�y.G•r,Ce/V,I,A 4\g/•_ ©2014 National Notary Association •www.NationalNotary.org • 1-800-US NOTARY(1-800-876-6827) Item#5907 J J S m Ami BEACH City of Miami Beach, 1700 Convention Center Drive,Miami Beach, Florida 33139, www.miamibeachfl.gov CITY CLERK Office Rafael E.Granado, City Clerk CityClerkc(`rmiamibeachfl.gov Tel: 305.673.7411 ,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. 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 sus•ended 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. Signature: Date: C:\Users\clerhatl\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\83LGQDDH\Lobbyist Registration Formrevised 5-30-2012.doc Miscellaneous Cash Receipt T' -„ry`: I 47.74:101 -04 1£ :.�1 001 121 , CITY OF MIAMI BEACH . zx No. H ; ill � h Cash 0 Credit Card heck#-.0 ���N. 24 Received of ".e-• - c)'' ” om t 4, 6N-ri it.,� . l Address (I 1 0 s.5 C '- E ..v.i) S.T- '`i{ liliAirii Ct. 3 't. For t5c. 'J�AE 6 L r E.5;3 r t =if 4t ( _'1 ,:(THIS INFORMATION MUST BE COMPLETED) , O���ffice of Finance.Director t )B �j/ .. 1. " I Lill r . ' L Account Number * r1 _ . , f „ ` ,' - N ;4:4..v Dept: C. 17y t.e � :EXT.y c" Preparers .-a�'.:,tf� .,4-,..' _ w a.c.2:ii n- .`^5.;_1-.�.•,,,,.2..in-�1ti,.rv"r. y�',9 1 -. , : _ S 4.7>'' w 4--1 .. ,4. „,. '_'3 ,,,2- a-,5.t1• ,; _.-- ,-„I.-24,- EL.',44:4�i•∎-i-,-7.,"?4c•1' +.,:'aic. a; 1 • 1* O N (J) F— O /) CC O O_ 1_ .— F - U O O C CD co O JI! iI m CO -O O CD gp S 1-00 O 'dt---,O -,=: 4— 0) >.CO L O r --•-_..--- O U 4--1 C1 0k S �.----- O •1— CO Q I` Cl) CY W-..e °�::_• ate, O O Cv } (A H Cll \`-zr -r •r CD = •� f0 C3 L.L r- '--- * � U S v