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Peter Chevalier - Carlota at South Beach LLC 5H 110'45-i'r=eL-r- MIAMI BEACH Office of the City ClerkRECE 1700 Convention Center Drive Miami Beach, FL 33139 zt ] © _8 E 1����: 26 2017 DEC -8 A 305.673.7411 LOBBYIST REGISTRATION FORM nrCl `�Cr MIAMI BE,,CH rCITY OF"�iAmi If! C" T;#= IAC t F THE Cli Lobbyist means all persons employed or retained, whether paid or not, by a principal who seeks to encotir �1h "sgage 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 City Code Chapter 2,Article VII, Division 3, entitled"Lobbyists," for additional information. Instructions: Please complete all sections of this form and submit the completed form,with the applicable fee,to the Office of the City Clerk. If you need more space to complete an answer, use a separate sheet(s) of paper. If you have nothing to report in a particular section, you must write "none" or "n/a" in that section. Any change to any information originally filed, or any additional City Commissioner or personnel who are also sought to be lobbied shall require that the lobbyist file an amendment to the registration form. The lobbyist has a continuing duty to supply information and amend the forms filed throughout the period that the lobbying occurs. Separate registration forms shall be required for each principal represented on each specific issue. I. LOBBYIST INFORMATION: Chevalier Peter A. NAME OF LOBBYIST (Last) (First) (Middle Name) Fulcrum Management Corp. I y ao) N)12-0 Sato Or 3 3 2(q b LOBBYIST BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) (786) 556-4569 pchevalier@chevIlc.com LOBBYIST BUSINESS TELEPHONE NUMBER CELLULAR TELEPHONE NUMBER EMAIL ADDRESS II. PRINCIPAL INFORMATION: Naves Juan C. NAME OF PRINCIPAL (Last) (First) (Middle Name) Carlota at South Beach LLC 7900 Oak Lane, Suite 400, Miami Lakes, FL 33016 PRINCIPAL BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) (305) 999-5501 naves@emprizaps.com PRINCIPAL BUSINESS TELEPHONE NUMBER CELLULAR TELEPHONE NUMBER EMAIL ADDRESS If the principal is a Corporation, Partnership or Trust, the following information MUST be provided pursuant to City Code Section 2-482(c): • NAME OF CHIEF OFFICER, PARTNER,OR BENEFICIARY: Juan C. Naves • NAME OF ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST: See attached. III. ISSUE TO BE LOBBIED: Describe with as much detail as is practical,including but not limited to a specific description where applicable of a pending request for proposal,invitation to bid,or public hearing number. mapfprats,anctk � .. . '' '' for the property located at 11 16th Street. IV. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED: Pursuant to City Code Section 2-482(a)(4), list the City Commissioner or City personnel sought to be lobbied,and whether the lobbyist has entered into any contractual relationship(paid or unpaid)with said City Commissioner or City personnel from 12 months preceding such commencement of service with the City to the present date,stating the general nature of the subject contractual relationship. Full Name of Individual and Contractual Relationship(If yes,explain) YES NO Title of Person to be Lobbied Planning Staff, City Development Boards, None X Land Use Development Committee None X and Commission 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. List any Business, Financial, Familial or Professional Relationship, or other relationship giving rise to an appearance of impropriety: N/A V. DISCLOSE RATE AND AMOUNT OF LOBBYIST COMPENSATION — Be Specific. (Note that a contingency fee is prohibited pursuant to City Code Sec. 2-485.3): $175.00/hour The following five(5)questions MUST be answered: 1) Pursuant to City Code Section 2-488,entitled"Prohibited Campaign Contributions By Lobbyists On Procurement Issues": _YesXNo: 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 City Code Section 2-490, entitled "Prohibited Campaign Contributions By Lobbyists On Real Estate Development Issues": _YesX.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 Map? 3) Pursuant to City Code Section 2-482(h), any person (except those exempt from the definition of "lobbyist" as set forth in Section 2-481)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 city clerk as required by this section, but shall not be required to pay any registration fees. YesX No: Are you representing a not-for-profit corporation or entity without special compensation or reimbursement? 4) Pursuant to City Code Section 2-481, the term "lobbyist" specifically excludes the following persons: Expert witnesses who provide only scientific,technical or other specialized information or testimony in public meetings; any person who only appears as a representative of a neighborhood association without compensation or reimbursement for the appearance,whether direct, indirect or contingent,to express support of or opposition to any item;and any person who only appears as a representative of not-for-profit community based organization for the purpose of requesting a grant without special compensation or reimbursement for the appearance. YesX No: Are you providing only scientific, technical or other specialized information; appearing as a representative of a neighborhood association without special compensation or reimbursement or representing a not-for-profit based organization for the purpose of requesting a grant without special compensation or reimbursement? 5) Pursuant to City Code Section 2-482(a)(4), a lobbyist who has within the past election cycle provided campaign consulting services to an incumbent member of the City Commission shall disclose such particular service on his/her lobbyist registration form and shall orally disclose such particular service before lobbying the City Commission at a public meeting. _YesXNo: Have you provided campaign consulting services to an incumbent member of the City Commission within the past election cycle?If yes.please list the incumbent members)of the City Commission: If yes,you must also orally disclose such particular service before lobbying the City Commission at a public meeting. VI. SIGNATURES UNDER OATH: ON FEBRUARY 28 OF EACH YEAR, EACH LOBBYIST SHALL SUBMIT TO THE OFFICE OF THE CITY CLERK A SIGNED STATEMENT UNDER OATH, LISTING LOBBYING EXPENDITURES, AS WELL AS COMPENSATION RECEIVED, FOR THE PRECEDING CALENDAR YEAR WITH REGARD TO THE SPECIFIC ISSUE ON WHICH THE LOBBYIST HAS BEEN ENGAGED TO LOBBY. A STATEMENT SHALL BE FILED EVEN IF THERE HAS BEEN NO EXPENDITURE OR COM NSATION DU G THE REPORTING PERIOD.1 ..Signature of Lobbyist: A, Date eli-10- I do solemnly swear or affirm that all of the foregoing facts, statements, and disclosures in this form are true and correct, and that I have read or familiar with the provisions contained in Chapter 2, Art. VII, Division 3, entitled "Lobbyists" of the Miami Beach City ode d all reporti • relauiremeIt . Signature of Lobbyist c Date 13/ill r Signature of Principal: , 1 ►ri\� ycigt-) Date VII. NOTARY SIGNATURE AND SEAL: LOBBYIST: PRINCIPAL State of 3;T\°ri d° State of County of: ;\j I 0 r')( act County of: Sworn o(or affirmed nd ubscr bed before me Sworn to(or affirmed)and subscribed before me this day of ,I4S ,20L1-by this_day of , 20_, by kif• C,fe ok NAME OF LOBBYIST NAME OF PRINCIPAL Produced ID 2C1 is pof --\-- _Produced ID FORM OF IDIFICATION FORM OF IDENTIFICATION Personall nnown _Personally Known ignature Nota Public Signature of Notary Public lneCCCI +0mr a(I0 ame of Notary,Typed, Printed or Stamped Name of Notary,Typed, Printed or Stamped (NOTARY S ii,r'1w, Mot4ry l t pi c.state of Ftorl (NOTARY SEAL) Vanessa Aitamirano s , ._ i 44r My r:ommission FF 914375 +► q, s 08,3,/2019 • t O, u` a BY CITY CLERK'S STAFF ONLY Annual Registration f LJ Yes[ ]No Amount, aid 4:>0.oU MCR#, --% �0 Date Paid /7.-I i-11 Lobbyist Registration m r received and verified by: -- ',10 A'3 ‘--- F:\CLER\$ALL\aFORMS\LOBBYIST FOORMS\Lobbyist"fgistration Form Revised 08-18-16 REG.doc Revised 08/18/2016 1 The term"lobbyist"specifically excludes the,following persons: Expert witnesses who provide only scientific,technical or other specialized information or testimony in public meetings; any person who only appears as a representative of a neighborhood association without compensation or reimbursement for the appearance, whether direct, indirect or contingent, to express support of or opposition to any item; and any person who only appears as a representative of not-for-profit community based organization for the purpose of requesting a grant without special compensation or reimbursement for the appearance. • • City of Miami Beach, 1700 Convention Center Drive,Miami Beach, Florida 33139,www.miamibeachfl.gov Office of the City Clerk Rafael E. Granado, City Clerk CityClerk@miamibeachfl.gov Tel: 305.673.741 1, Fax: 305.673.7254 NAME OF LOBBYIST: Peter A. Chevalier 1) LOBBYIST FEE EXPENDITURE AND COMPENSATION STATEMENT Pursuant to City Code Section 2-485(d), the City Clerk shall notify any lobbyist (or principal) who fails to file timely a Lobbyist Fee Expenditure and Compensation Statement (Statement). In addition to any other penalties that may be imposed as provided in Section 2-485.1, a fine of $50.00 a day shall be assessed for Statements 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 of each year, shall be automatically suspended from lobbying until all fines are paid, unless the fine has been appealed to the Miami-Dade County Commission on Ethics and Public Trust. I hereby acknowledge that on February 28 of each year, I shall submit to the City Clerk a signed Statement under oath listing all lobbyist expenditures, as well as compensation received, for the preceding calendar year with regard to the specific issue on which I have been engaged to lobby. 2) LOBBYIST WITHDRAWAL Once an issue I have registered to lobby has concluded or I am no longer lobbying on that issue, I shall immediately file a Notice of Withdrawal with the Office of the City Clerk. 3) ANNUAL LOBBYIST REGISTRATION FEE I understand annual registration of all lobbyists shall be required for each 12-month period commencing October 1 of each year, and the fee for such annual registration shall be 50 .00 pursua .ection 2-482 of the Miami Beach City Code. Signature of Lob yi Date F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form Revised 08-18-16 REG.doc 7 CITY OF MIAMI BEACH DEVELOPMENT REVIEW BOARD APPLICATION DISCLOSURE OF INTEREST 1. CORPORATION, PARTNERSHIP, OR LIMITED LIABILITY COMPANY If the property that is the subject of the application is owned or leased by a corporation, partnership, or limited liability company, list ALL of the owners, shareholders, partners, managers, and/or members, and the percentage of ownership held by each. if the owners consist of one or more corporations, partnerships, trusts, partnerships, or other corporate entities, the applicant shall further disclose the identity of the individual(s) (natural persons) having the ultimate ownership interest in the entity.* Carlota at South Beach, LLC NAME OF CORPORATE ENTITY NAME AND ADDRESS % OF OWNERSHIP Juan Carlos Naves 100% 7900 Oak Lane, Suite 400 Miami I akes FI 33016 NAME OF CORPORATE ENTITY NAME AND ADDRESS % OF OWNERSHIP IF THERE ARE ADDITIONAL CORPORATE OWNERS, LIST ALL SUCH OWNERS, INCLUNG CORPORATE NAMES AND THE NAME, ADDRESS, AND PERCENTAGE OF OWNERSHIP OF EACH ADDITIONAL OWNER, ON A SEPARATE PAGE. NOTE:Notarized signature required on page 9 FILE NO. cellaneous Cash Receipt OF MIAMI BEACH tt 1 PA1 1 . 418570 .--1 , /:ash D Credit Card Check# DEC 0 8 20 x# 3, �g: 20f (�g� 1A1 l ,EACH . gyred of I ��� 1 r k,el t ,. aiiRl(rt �i ) � t �'^ '7 Y3 Y 1 S INFORMATION MUST BE COMPLETED) Office of Finance Director -A ' :ct 1- 4-1 -t.�'.+'�"-, '� � , 1.-j,'g; r(j 0 "fi b By it.Number. sr: 1)GI-\( eta" 1i'"--' Dept: .- Cie, , EXT: ' /,.