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Adrian Dabkowski - EBJ Sagamore LLC 1 L(elc ;IA act- I L i 1 Ce(i,es DocuSign Envelope ID:FO8F44E3-56D4-4635-944E-3094O401C86E RECEIVE M AM I B EAC ° Office of the City Clerk °C T 2 1700 Convention Center Drive 0 2022 Miami Beach, FL 33139 C/7-, 305.673.7411 oPF,G 1 F MIAMI B� LOBBYIST REGISTRATION FORM CST}' AC/ 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 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: Dabkowski Adrian NAME OF LOBBYIS i (Last) (First) (Middle Name) Kimlev-Horn & Associates 8201 Peters Road,Suite 2200 Plantation Florida 33324 LOBBYIST BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) 954-535-5144 Adrian.Dabkowski©kimley-horn.com LOBBYIST BUSINESS TELEPHONE NUMBER CELLULAR TELEPHONE NUMBER EMAIL ADDRESS It. PRINCIPAL INFORMATION: Granda Javier NAME On PRINCIPAL (Last) (First) (Middle Name) EBJ Sagamore LLC 4100 NE 2 Avenue,Suite 202 Miami Florida 33137 PRINCIPAL BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) 305-728-8240 javier@lionstone.net PRINCIPAL BUSINESS TELEPHONE NUMBER CELLULAR TELEPHONE NUMBER EMAIL ADDRESS Pursuant to City Code Section 2-482(h)(1)(al: A principal of any corporation,partnership, or other entity who appears as a lobbyist on behalf of that entity,without special compensation or reimbursement for the appearance,whether direct,indirect,or contingent,to express support of or opposition to an item shall register with the Clerk as required by this subsection but shall not be required to pay any registration fees. 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(if none,write N/A): J. Grandd • NAME OF ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY,A 5%OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST(if none,write N/A): Please see the attached. Page 1 of 5 (4124 14144:111N,'1/:)! ,III ,I III DocuSign Envelope ID FO8F44E3-56D4-4635-944E-30940401C86E Ill. 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. Lincoln Road Improvements, Development Approvals& Permitting Issues, including but not limited to the Historic Preservation Board, Design Review Board, Planning Board, Board of Adjustment, Land Use Development, City Commission, and any City Workshops or Committees, if necessary, relating to the properties located at 1 Lincoln Road and 1671 Collins Avenue in Miami Beach, Florida. 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 Staff for the Planning & Building Department None X Public Works & City Administration, PB, HPB, BOA None X DRB, City Commission, and Mayor as necessary None X Land Use &Sustainability Committee 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(if none,write NIA): None 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): S355.00 per hour Page 2 of 5 )„v„ovi, ;crn/a ai,�aa<eaf=,ann6niaelrnn (( ��III rnl n. of 14 rnoecita�i 'OE �i DocuSign Envelope ID:P08F44E3-5604-4635-944E-30940401C86E The following six(6)questions MUST be answered: 1) Pursuant to City Code Section 2-488,entitled"Prohibited Campaign Contributions By I obhyists On Procurement Issues": _Yes XNo: 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": _Yes XNo: 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. _Yes x 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. _Yes X 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 2-491(1), no campaign consultant shall lobby the City Commission for a period of 12 months following the swearing in of any elected official(s)for whom the campaign consultant provided campaign consulting services within the past election cycle.See Section 2-491 for more information. -Yes XNo: 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 member(s)of the City Commission: —Yes XNo: If yes, has it been less than 12 months since the elected official(s) whom you provided campaign consulting services was sworn in? 6) Pursuant to City Code Section 2-482(a)(4)a., a lobbyist who has within the past election cycle provided campaign consulting services to an incumbent member of the City Commission (which lobbying activity is not otherwise prohibited by Code section 2-491) 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. _Yes x No: 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 member(s)of the City Commission: —Yes XNo: If yes, were you promised or did you receive economic consideration in exchange for campaign consulting services? TO BE COMPLETED BY CITY CLERK'S STAFF ONLY Annual Registration tee: [`f Yes I I No Amount Paid$ �/ C ``MCR# ]V� v Date Paid (� ri' . • Lobbyist Registration Form received and verified by: 3 J F:\CLER1$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form Revised 09-20-18 REG.doc Revised 09/20/2018 Page 3 of 5 Doeve,d,'ID /CC?D/N0 c(32 43Cn-8HS8.41 Md)198R/01 . Pape 30121 t4 ,;1,„,,,A(Si 1111 �I III DocuSign Envelope ID:F08F44E3-56D4-4635-944E-30940401C86E 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 COMPENSATION DURING THE REPORTING PERIOD.' Signature of Lobbyist: Date 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 am familiar with the provisions contaired in Chapter 2. Art. VII, Division 3, entitled "Lobbyists" of the Miami Beach City Code and all reporting requirements. Signature of Lobbyist: (--DocuSpoce by. Date Signature of Principal (,otW�!4'JyAln I Date VII. NOTARY SIGNATURE AND SEAL: LOBBYIST: PRINCIPAL State of Florida State of Florida County of Miami-Dade County of: Miami-Dade Sworn to(or affirmed)and subscribed before me, Sworn to(or affirmed)and subscribed before me, by means of❑ physical presence by means of❑ physical presence or❑online notarization, or® online notarization, this day of , 20 , by this 1q day of October 2022, by Adrian Dabkowski Javier Granda NAME OF LOBBYIST NAME OF PRINCIPAL _Produced ID Produced ID FORM OF IDENTIFICATION FORM OF IDENTIFICATION X Personally Known x Personally Kno Signature of Notary Public Signature of Notary Public Diana Ramos Name of Notary, Typed, Printed or Stamped Name of Notary, Typed, Printed or Stamped (NOTARY SEAL) (NaJogYSFti.1L- - - - -___ ___ 1 Diana Ramos Commission 0 GG 308355 1 Notary Public-State of Florida ' The term'lobbyist"specifically excludes the following persons: I My Commission Expires Apr 10.2023 Expert witnesses who provide only scientific,technical or other specialized flRurnr-imnrnimo dirsrmm marahnr75„ y 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. Page 4 of 5 ----- War UOCVenry ID-7CGTWStl-4732-17C8-BR5N ADbri1 PP2r 70E 'III t nl' Doc erify I - CC Pape A o124 41DGD1GG2C70C II DocuSign Envelope ID:ACBE9352-A65A-452A-93FE-FC4A262F8202 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 COMPtENSATIOblbDURING THE REPORTING PERIOD.' Signature of Lobbyist: Q�VIALt Oct�I�OWS�Ct Date 10 19/2022 7bo0rFaoF0o3443.. 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 am familiar with the provisions contained in Chapter 2, Art. VII, Division 3, entitled "Lobbyists" of the Miami Beach City Cod ando''e__0irspb'rting requirements. Signature of Lobbyist: awl �r �DWS�I Date ip igr2rt29 5aeerr.+x'•�25�443 Signature of Principal: Date VII. NOTARY SIGNATURE AND SEAL: LOBBYIST: PRINCIPAL State of Florida State of Florida County of: Miami-Dade County of: Miami-Dade Sworn to (or affirmed)and subscribed before me, Sworn to (or affirmed)and subscribed before me. by means of❑ physical presence by means of C physical presence or E online notarization, or ® online notarization, this 19 day of October ,20 22, by this_day of October . 2022, by Adrian Dabkowski Javier Grande NAME OF LOBBYIST NAME OF PRINCIPAL _Produced ID Produced ID FORM OF IDENTIFICATION FORM OF IDENTIFICATION x Personally Know L ]..:. x Personally Known .�.a Signature of Notary Public Signature of Notary Public Diana Ramos Diana Ramos Name of Notary, Typed, Printed or Stamped Name of Notary, Typed, Printed or Stamped .ram—.—,,.a ,., ——�+—--- e w , (NOTARY SEAL) Diana Ramos 1 Commission 1t GG 308355 1 4 Notary Public State of Florida 1 1 The,'My Commission Expires Apr 10,2023 g persons: ` ` T";4;-7 — :r_sI or other specialized information or testimony in public meetings;any erson 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. Page 4 of 5 DocVerlty ID:8OEBFD24.70130 47E8-1305e-ki5r'nnur1 ion Pepe 4 0120 4B5CAAD81334A ,III g9;F R B II w ww AncveuN cone DocuSign Envelope ID:ACBE9352-A65A-452A-93FE-FC4A262F8202 MIAMI BEACH City of Miami Beach, 1700 Convention Center Drive,Miami Beoch, Florida 33139,www.miamibeachf.gov Office of the City Clerk Rafael E.Granado,City Clerk CityClerk@miamibeachfl.gov Tel:305.673.7411, Fax: 305.673.7254 NAME OF LOBBYIST: Adrian Dabkowski 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 $500.00 pursuant to Section 2-482 of the Miami Beach City Code. Ducu5i0neo by. 0. O11n pai LDWsL 10/19/2022 �_. gPC.Q7,19;41P'1d1; Signature of Lobbyist Date CLtil3ALL'.aFORMSILOBBYtST FORMS\Lobbylst Reg,soation Form Revised 03-11-20 REG.doc Page 5 of 5 DocVe�tIy ID.8oEBFD24 7000•47E0-BOG5-BSCAAD8,334A ,III Etra ,I III ' Duc eltly ID can Pageb o120 5PSCA/D111334A DocuSign Envelope ID:F08F44E3-56D4-4635-944E-30940401C86E EXHIBIT "A" Organizational Chart of FRI Sagamore LLC nag of lido �s a Udo Uoromne Ds We tieretera DI Ma Deeraeins Corp.(FM l Vel .t A fn.} 1.v,uC(rat t o Inc.(iU i sa4prr E' ry Itt l � t� � f�i J l t v i l .67%1 29.5% 35% i_S}n 31.66% 1.67% -- ++ Di tk10 Beach Resort I Managers of DI Di Udo Beach Resort Parent CIC,and l Puma Ur free) ('nj E815agamore LLC: Lionstone Group: 1. Diego Lowenstein tc o% 2. Javier Grande r Kanavos Group: I' ERI r"'m 1- Paul C Kanavos 1D 2. Dayssi Olarte de Kanavos ben-Jose(Group, I. Ron Ben-1osef • = 2. RonenBen-:osef • Lionstone entities on page Z. - Kanavas entities on page 3. ' • Bert-Josef eMfties on page 4. wwwd CKy N'on 7D78E4-4B2-43C 8-SB58-4D6D1882E70E Page 21 of 24 ?74LNiD1R82E7nF III 'I III DocuSign Envelope ID:F08F44E3-56D4-4635-944E-30940401C86E i toaww. . istuaE� �-Gawk•, (� wwu�'yCPrsin/ Lionstone Group COOKY �ATiRR (\ WENSTFi/ \ (,OMM@67EIM AOANOELOW 'M j LQd/Ei.S�F.IN 3.81% 3.81%\ 10.48% 10.48% 10.48% 1f1148% 100% I I \ / 1 ti Lav n stein Fandlylrust (11lrocaEle)(BNIj 100% lowesten holdings Uri. 1 / L 100% // r-is ..._ (liana dat)ltd. I i 100% f 1 /,/ , \ 50.45% • xsxbsse:}rsx+s�.6ec. ifil 100% Maslow DIM.19 U.0 LI.r.gas-Aocte DI Lido 6P kw. (Ft.) 35% 13% ti Kanavos entities on page 3; 1 Di lido&eadl Resort Ben-lasef errttties on page 4- ( Parent 11C(DE) ww wJO ticx:ify IU:7CC7DT8B-M173Y-43C8-BB58-4D6U188YE7OE Page 22 of 24 Y14U6U1tltlYt/Ut ,III ,III • www vn,M cnm DocuSign Envelope ID.F08F44E3-56D4-4635-944E-30940401C86E 1 Konavos Group 1 P.A.4 C. 0 TEJ ( Kuuvns r w oos Pau*C.KIvo\ Iyast Poet I SCOCT I SO% 50% i 54% I i An 141114 r t1Pt 134 timfy Sheldon Lure T I I If�wwDynntT `IKamm I 1 Tam 2011 I .67% 238866%1 450323%I 6.78%' 12.39452%1 5.05632%: 93214% 1 2_]5299% : 27.93632%1 27.91637%I 9.aosno%1 i Rag Di Lido Vereu.nn,LW. I 29.:% tionswne enwes on page 2; 1 p Best-Josef ereMies on page 4. ar Lido Breath Resort vanst t!s Me • DoeVefify ID:I www fnrv.,N�Cm70788-4732-43C 8-Be58-ID601A89E70F. Pape 23 of 24 234D6D1882E70E ,III Mali III-— DocuSign Envelope ID FO8F44E3-56D4-4635-944E-3Og404O1C86E , 1 Ben-Josef Group i Rowr \',, tt( RON BEN- rc-1-----....\NEN 1 (---lit,v1T .1 MEUNUtN i �J05EF BEN-106EF KRf.US zsx 2sx ux zsx �_` The Edeed Bert- j Josef and Udia Ben- i Senn-JosefGrouq Each of(J) Ronit Neuman, (II) Ron Ben-Josef, (lii) 1 Josef Irrevocable j Nolan.SIC Konen Ben-Josef and(iv)Ravit Kraus are the trustees Trust + (NY)i \ / of The Edeed Ben-Josef and Lida Ben-Josef Irrevocable Trust 100% 100% EBJ Properzies.:IC . E3f Swears ry (oE) UX toq 1 31.66% 1.57% t Di IMP March 1 tiautxrre entiiies on Rage 2; _ K4navos mtiti:s on page 3. Pbs,�tst tiC (DE} J DocVer: 10:7C0 7D768-475243C8-6B28-4u u1862E/OE Page.24 of 24 244D6D1682E70E ,�� '1 II w ww t6.:waiN<xmi Miscellaneous Cash Receipt No 430782 CITY OF MIAMI BEACH ❑Cash ❑ Credit Card ❑Check# 20 Received of Address For MEdF hiiatellaneous- MCR-2023 G 751-0008 Adrian V... 10121/2022 11:30AM OPEN(MCR) Paygment Amount: 1;900.00 (THIS INFORMATION MUST BE COMPLETED) Office of Finance Director Account number: By Preparers Dept: EXT: 0