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-111 B E. RC OW RADELL & F ER NAN D EZ ZONING, LAND USE ANID ENVIRONMENTAL LAW Direct: 305-377-6235 E-Mail: BFernandez(@,BRZoningLaw.com www.BRZoningLaw.com VIA HAND DELIVERY January 3, 2011 Mr. Francisco Garcia, Director Director Planning Department Miami Riverside Center Planning Department 444 SW 2nd Avenue, 3rd Floor Miami, FL 33130-1910 Re: Exception for Little River Club - 770 & 776 NE 80th Street, Miami, FL Dear Mr. Garcia: This law firm represents the Little River Club, Inc., a not -for -profit organization, in relation to the referenced Exception. The Applicant is requesting an extension of a previously granted conditional use permit under Ordinance No. 6871, Article V, Section1 (6) (c), which permitted the use of the property for off-street parking in conjunction with the commercial lots on NE 79th Street. This use was granted in recognition of the fact that the denial of the use would result in certain practical difficulties and unnecessary hardship to the owner. The applicant is requesting an extension of the conditional use permit for a twenty (20) year term as provided in Article 7.2.6 (a) of the Code. For over twenty (20) years, the Little River Club has been serving the community providing important rehabilitation counseling on the abutting commercial property. During this time, the members of the Little River Club utilized the surface parking area in a manner that is respectful of nearby residential areas. In particular, the parking has been well maintained and a gate has been maintained at the access onto NE 80th Street. The Little River Club is requesting approval of this exception based on. the fact that the use continues to operate in a manner that is compatible with the surrounding area and based on the fact that there is no alternative vehicular access to the Property. WACHOVIA FINANCIAL CENTER • 200 SOUTH BISCAYNE BOULEVARD, SUITE 850 • MIAMI, FLORIDA 33131 PHONE. 305.374.5300 • FAX. 305.377.6222 • WWW.BRZONINGLAW.COM Mr. Francisco Garcia, Director January 3, 2011 Page 2 It is significant to note that the plan submitted with the Exception proposes landscape improvements within both swales abutting the Property along NE 80th Street. The new landscaping includes oak trees that will be fourteen feet (14') tall at time of planting and that will complement the existing cherry hedge along NE 80t11 Street. The oak trees will also create a shade canopy along the street as well as provide additional visual screening of the parking area. For all of the foregoing reasons, we hereby request your favorable review and recomunendation. BF/bl Enclosures Sinc en Fernandez BERCOW RADELL & FERNAN DEZ ZONING. LAND USE ANC) EN VI F ON MENTAL LAW PLICATION MIAMI 21 he deadline to =file,the complete application with supporting documents is the first five working days of each month 'from '8:00 am until 3:00 pm, except on the fifth day, at 12:00 pm. The application submittal date is the{date stamped by Hearing Boards' staff on this page. The `responses to this application must be typed and signed in black ink. All pertinent and accurate Information/documentation; i.e , theplans, reports, exhibits, shall be presented at the time of filing, in.;addition to'the paid receipts The applicant is responsible for the accuracy of the information contained': in, the application -and all supporting materials. Should you wish, you could bring the material§ for review'before the; deadline to ensure completeness. You will be µresponsible, if needed, to bring an interpreter for the English language to any presentation before` city boards, committees and the city commission. A valid power of attorney will be required if neither applicant or legal counsel representing the applicant execute the application or desire to make a presentation before city boards, committees and the city commission. All documents, reports, studies, exhibits (8 1/2 x11 ") or other materials submitted during this process will be kept as part of the record. An additional fee to record resolutions will be charged, and it is determined contingent upon fees charged at the time of recordation by the Miami -Dade County Recorder's Office at 22 NW First Street, First Floor. Upon arrival, ask for a certified copy of the resolution. They will keep the original, but please have them mail it to us, and bring the certified copy to our office. Copies of City Commission resolutions/ordinances can be obtained at our website through the "Legislative Hub", or for certified copies, please contact the Office of the City Clerk at 305-250-5360 or at 3500 Pan American Drive. ORDINANCE NO. 11469, CODIFIED IN CHAPTER 2, ARTICLE VI OF THE CITY CODE STATES THAT ANY PERSON WHO RECEIVES COMPENSATION, REMUNERATION OR EXPENSES FOR CONDUCTING LOBBYING ACTIVITIES TO REGISTER AS A LOBBYIST WITH THE CITY CLERK, PRIOR TO ENGAGING IN LOBBYING ACTIVITIES BEFORE CITY STAFF, BOARDS, COMMITTEES AND THE CITY COMMISSION. A COPY OF SAID ORDINANCE IS AVAILABLE IN THE OFFICE OF THE CITY CLERK (MIAMI CITY HALL), LOCATED AT 3500 PAN AMERICAN DRIVE, MIAMI, FLORIDA, 33133. Ordinance No. 12918 states that each person or entity requesting approval, relief or other action from the City Commission or any of its boards, authorities, agencies, councils or committees regarding any issue, shall disclose at the commencement (or continuance) of the public hearing(s) on the issue, any consideration provided or committed, directly or on its behalf, for an agreement to support or withhold objection to the requested approval, relief or action. The Disclosure of Consideration Provided or Committed for Agreement to Support or Withhold Objection Affidavit included in this package must be submitted with the application. The applicant must, at the commencement of any public hearing on the issue, if there is any disclosure to report, read the disclosure into the record. Also, the applicant must supplement the affidavit if there is any new information or additional information to disclose. Applications given to customers do not constitute action from the City of Miami without plans review and written comments from the Office of Zoning. Revised May 2010 CITY OF MIAMI Hearing Boards Ph: 305-416-2030 444 SW 2nd Ave 7d' Ploor Miami, FL 33130 www.miamigov.coin/hearing_boards 3 EXCEPTION APPLICATION lease refer to Article 7.1.2.6 of the Miami 21 Code for Exception information. pplican en Fernandez, Esq. on behalf of Little River Club, Inc. ubject.`propertyaddress(es) andfolio number(s): 770 NE 80 Street (01-3207-017-0030) and 776 NE 80th:Street(01-3207-017-0020) ` t VA One (1);original survey dated within six (6) months from the date of application prepared by a State of Florida registered land surveyor=: One (1) original 24x36" pla , ,signed and sealed by a State of Florida registered architect or engineer `showing<,4property, boundaries and proposed structure(s), parking, landscaping, etc.; building,�elevationsand dirnensions and computations of lot area and building spacing. 5. 'After all;; departments: initial and date the plans, two (2) 11x17" and one (1) 8%x11" copies of the original` plan,:: in' addition to the survey. 6. Original and current Zoning Write -Up signed by'Office of Zoning designee. 7. The subject property(ies) cannot have any open code enforcement/lien violations, unless the request, if granted, would remedy the violation. 8... Copy of the lobbyist registration processed by the Office of the City Clerk, if applicable. 9. At least two photographs showing the entire property showing land and improvements. 10. A clear and legible copy of the recorded warranty deed and tax forms of the most current year showing the present owner(s) and legal description of the property. 11. A clear and legible copy of the subject property address(es) and legal description(s) on a separate sheet, labeled as "Exhibit A", to match with the current survey's legal description. 12. Affidavit of Authority to Act and the Disclosure of Ownership of all owners and contract purchasers, if applicable, of the subject property (see pages 4 and 5). 13. Original Disclosure of Consideration Provided or Committed for Agreement to Support or Withhold Objection Affidavit. 14. Certified list of owners of real estate within 500 feet of the subject property (see pages 6 and 7). 15. For all corporations and partnerships indicated:, a) Articles of Incorporation; b) Certificate from Tallahassee showing good standing, less than one (1) year old; c) Corporate Resolution or a Power of Attorney signed by the secretary of the Corporation authorizing the person who signed the application to do so; d) Non-profit organizations: A list of Board of Directors less than one (1) year old. Revised May 2010 CITY OF MIAMI Hearing Boards Ph: 305-416-2030 444 SW 2nd Ave 7'' Floor Miami, FL 33130 www.miamigov.com/hearing_boards 4 EXCEPTION APPLICATION 16 What is°the acreage'of the,project/property site? 0.28 acres hat is„the purpose of this, application/nature of proposed use? surface parking Is. the• property within the; boundaries of a historic site, historic district or archeological zone? lease contact the Planning Department on the 3rd Floor for information. No 19 Is the'property withm.the boundaries of an Environmental Preservation District? Please contact the Planning Department on'the 3t ; Floorfo f information. No 204 Cost of processing according to,Section 62-156 of the Miami City Code*: a. Exception Permit g� $ 800.00 n cz > .mvx<5'f Extension of tie for Exception $ 500.00 c 'Exception Permit Requiring City Commission Review $ 2,000.00 Public hearing and public meeting mail notice fees, including cost of handling and mailing per notice $ 3.50 Surcharge equal to applicable fee from item above, not to exceed eight hundred dollars ($800.00) except from agencies of the city; such surcharge to be refunded to the applicant if there is no appeal from the applicant or a property owner within five hundred (500) feet of the subject property. *Pursuant to Ordinance 12719, all planning and zoning fees in excess of $25, 000.00, shall be paid in the n of a cerFlfiedjcheck, cashier's check, or money order. Signature Name Ben Fernandez, Esq. Telephone 305-377-6235 Mailing Address 200 S. Biscayne Boulevard, Suite 850 STATE OF FLORIDA -- COUNTY OF MIAMI-DADE. Miami, Florida 33131 E-mail Fernandezc BRZoningLaw.com The foregoing was acknowledged before me this 3 day of January, 2011, by Ben Fernandez, Esq. who is a(n) individual/partner/agent/corporation of Bercow Radell & Fernandez, P.A. a(n) individual/partnership/corporation. He/She is personally known to me or who has produced as identification and who dill (did t) tape an oat (Stamp) Revised May 2010 Sig ature CITY OF MIAMI Hearing Boards Ph: 305-416-2030 444 SW 2nd Ave 7th Floor Miami, FL 33130 www.miamigov.com/hearing_boards • 5 EXCEPTION APPLICATION 'S';CLOSURE OF OWNERSHIP /List the owrer(s) of the subject` property and percentage of ownership. Note: The Miami City Code .,requires disclosure of all; parties having a financial interest, either direct or indirect, with respect to a presentation, request or petitlom Accordingly, disclosure of shareholders of corporations, beneficiaries of trusts and/or any other interested‘,patties, together with their address(es) and proportionate interest are required. Please supply ad'ditionallhsts, if necessary. Little River Club, Inc. 770 NE 80 Street (01-3207-017-0030) and 776 NE 80th Street (01-3207-017-0020) 2. List all street address(es) and legal description(s) of any property located within 500 feet of the subject property owned by any and all parties listed in question #1 above. Please supply additional lists, if necessary. Street Address(es): 753 NE 79th Street (01-3207-017-0260) Ben Fernandez, Esq. Owner(s) or Attorney Name Legal Description(s): Lots 50, 51, 52, 53, and 54, less the South 5 feet thereof, in Block "A" of COMMERCIAL SHORE CREST, according to the Plat thereof, recorded in Plat Book 17, at Page 16, of the Public Records of Miami-Dade-6Qunty, Florida Ow er(s) or Attorney Sign-ture STATE OF FLORIDA -- COUNTY OF MIAMI-DADE The foregoing was acknowledged before me this day of January, 2011, by Ben Fernandez, Esq. who is a(n) individual/partner/agent/corporation of Bercow Radell & Fernandez, P.A. a(n) individual/partnership/corporation. He/She is personally known to me or who has produced as identification and who did (did not) take an oath. (Stamp) BETTY U.ERENA 4 MY COWAISSION Y DD 860413 EXP$RES: Mesh 5, 2014 Banded Tin Way Miic UndRwiNors Revised May 2010 CITY OF MIAMI caring Boards Ph: 305-416-2030 444 SW 2nd Ave 7th Floor Miami, FL 33130 www.miamigov.com/hearing_boards 7 EXCEPTION APPLICATION F'IDAVIT OF AUTHORITY TO ACT Before me.this`day,"the undersigned personally appeared Ben Fernandez, Esq., who being by me first deposes.and ;says st y That he/she is, the owner. or,the� legal representative of the owner, submitting the public hearing application as required by the'`Code/of. the City of Miami, Florida, affecting the real property located in ,the`'City of Miami', as listed on the foregoing pages. 'That' all owners ,,who he/shed represents, if any, have given his/her full and complete permission for &him/her toact in his/her behalfmforithe change or modification of a classification or regulation of zoning as set out in the?foregoing petition, 0 including or 0 not including responses to day to day staff inquire 3. That the foregoing and following pages are part of this affidavit and contain the current names, mailing addresses, telephone numbers and legal descriptions of the real property of which he/she is the owner or legal representative. 4. That the facts, as represented in the application and documents submitted in conjunction with this affidavit, are true and correct. Further Affiant sayeth not. Ben Fernandez, Esq. Applicant(s) Name STATE OF FLORIDA -- COUNTY OF MIAMI-DADE Ap licant(s) Signature rt The foregoing was acknowledged before me this day of January, 2011, by Ben Fernandez, Esq. who is a(n) individual/partner/agent/corporation of Bercow Radell & Fernandez, P.A. a(n) individual/partnership/corporation. He/She is personally known to me or who has produced as identification and who did (d's not take -n oath. (Stamp) Revised May 2010 CITY OF MIAMI Hearing Boards Ph: 305-416-2030 444 SW 2nd Ave 7d, Floor Miami, FL 33130 www.miamigov.com/hearing_boards Exhibit A Legal Description Lots 8 and 9, in Block "A" of COMMERCIAL SHORE CREST, according to the Plat thereof, recorded in Plat Book 17, at Page 16, of the Public Records of Miami -Dade County, Florida. Addresses: 770 NE 80th Street, Miami, FL (01-3207-017-0030) 776 NE 80th Street, Miami, FL (01-3207-017-0020) before me Iha1 she executed the lame WITNESS my hand •rid 0t6uat seal .n the January A D 1990. My coarmipsion expires: lily . • .. r•;. .issa •t un to: (anrlos. 811 dM aosd stamp4l mYM4pe) A,m. fhls Instrument Plepud by Shirley Woolf, Esquire 1101 Arthur Godfrey Rd, 1222 .aaoea Miami Beach, Florida 33140 P.03311y APpnl:e,3 Parcel Idenllllclllon Volta) W.W.I ). 01 3207 017 0020, 01 3207 017 0030, 01 1207 017 0260 10 d S9 • VAR 4.I0V1 1143 on Ion e.delsa.q a0T0 1a11aN10 0110 .talata.r r t/1ee) «: I4403iC38I2 '93 JAN 23 P.•f 2 28 RAOICO roam •w 90R02733t Dotun,epLary Stamps l.ollcrted 1 a tS.OJ 3 10 . �� . SURTAX Our: St,unps Collected Class "C" Intangible Tax Collected $. Miichartl P. tinker,Clrrk, Date County, Flp, Sy..a .. 41 d' ?> .`f�... . DC SPAT. awrl ihle ant spat 0EW,lol1a 04TA N 3r�n,, "vJ h„en•,h. . 1 .1 y„rr•I •... •„nr00l' tfat ttuii,4tiwb usa•W ,W r,ra•1 hra• Mra y.�tni".�e, „�.•• urn. ,n n u.Am nt..rp",Iwn, •Mall.IM r•n.r.l 'This Indenture, Moth.:hn �—' V^" day of January Between LILLIAN g, NO1,F, an unromarriod widow; 1. D. 19 o0 ..1 th.. l.n,�•n ••+ Dade o• the `e+tv of Florida • past Y of Ile fintroa,t. and L17TLE RIVER CLUB, INC., a Florida not for Profit Corporation, el +I• • ( ..r Dade to Ow Stow of Flor-ida evlm.. poi afire elates u 754 N.F:. loth Street, Miami, Florida 331333 tow y •d J.• .a• rid port lfJitnesseth. non lb, ..1,1 Pan Y of au. fort not for and to ,•onr,deratlon of the rum of TEN (S10.00) Dotfan, io her tri 1 1 petal 10. th,..no( part y of th.• second part, the ree•otpl wharaal, is hsraby arinowl. ,•dated hu s urnered l..egntnrd nnsl lead to the ,tad purl Y of the wand part, it`d hale ••.( .n .,v.• t..,,.•r al„• 1..l1...r...et. ,h•.• rtlo•tI Iw.d utnuu• mu1 lr.otr In At. County of Dade '41.th. 01 Florida too., Lots 50, 51, 52, 53 and 54, less the South 5 feet thereof, and Lots R and 0 in Block "A" of COMMERCIAL. SHORE CREST, according to the Plat thereof, recorded in Plat Book 17, at Page 16, of the Public Records of Dade County, Florida. SUBJECT TO: 1. Taxes for the year L990 and subsequent years. 2. Conditions, restrictions, limitations and easements of record, if any, without Intent to reimpose or reinstate same. 3. Applicable zoning ordinances of such govorrmental authorities having jurisdiction hurcover. Arid At. lord putt y of ale foal port do ashe.ohv Italy u•ananl Ile late to raid land. and a, 1I daf.nd tl• 'ono 0parnsl (h1 IOu•ftti .latm. of ofl mesons lehumsuee•rr IR Witness Thereof, The au.d pari y of the fort part lass 1etaunto 110r hood nod 3va1 Ihv troy Arid yea. fort abate woUlvn S,pnrd..vutod and dah.•rred to rho 4r..uvu•v 0f • St•1)F. Ur }L1hRlh\, Ctll $ 1'1' 11t DADE I. . s 111, LL11�an E. i+iolr l� y. ..; ^I ••••'•a! /ndaVa awe 1••li 'ilbt P. billti10EN b.r_•s 1 tet.9T t HEREBY CERTIFY shoe on tads day, betore ma, an oll.ur doh Aulhunrrd .n the• SUM al0reu,d and in ihr Cauniy aforesaid ta,.u)te arinawlydemenlr, personally appeared LILLIAN E. WOLF • 44 "••. gar'° to too lnuwn to be the preson deunbed in and who aeew. afi'and she .c►aowled1ed ' Q��i�j�tJtf�SY' Counly And $4te%�ialrateie,lrl ..the ' day 0t xot.arYw�,i��..sea ....7519.brYetx...ar.lazye. NE ca)o T-14 srF)-E,Er • • tx, sTIN CEkisT) cc CHAIN LINK 1:8N 1E;1 "Th (-2.-1)(AIT:6T:i1 ...___ / -1, • r a 0 -0c2.00 Przf P- . 0 ( ,,,‘, „id OH - G.. u rr- 5 c,,I0 „., . /• g,3i_0,.. C., ..1' ' /4 / E• /Yt.S. .• C.) .---' .* •/ 1 04 , Z , .- :!'' CC •En // • // n/ .. , „." c.; „, 10::NGW:.8.:51 >6 / t< --./ lil ,/' :51?"11fc..q; . 7 / '7' J101.961314..i isl G- ' ; is I / Al-,I;I:qN.O.: W. il:li ;:va !,;( /'/ Tp.f:Ey'r.T)•N--- ''. 4 • ,,,) . P/N •C ES 1 / / // ' / / ,,./` ,. --51.:S.ii;EW•r". • .0g&S 000. (Ir ,11/ / • / - ex.1.55-1N q- ?Agi-5 )):•1•Cl- r 510 io.")0o11)UrrieSiV6 (7./1 QS i•"--) RAN PI cAtVgD sppite5 ' • ?(*) Imr rt(NIOlCr)e -5`yrn3c1L.S r\t\16' I i•ISTin-L- . A cc° cztol c. 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Filing Information Document Number 707751 FEUEIN Number 591677644 Date Filed 08/27/1964 State FL Status ACTIVE Last Event AMENDMENT Event Date Filed 09/04/1986 Event Effective Date NONE Principal Address 755 NE 79TH ST MIAMI FL 33138 Changed 01/21/2000 Mailing Address 755 NE 79TH ST MIAMI FL 33138 Changed 01/21/2000 Registered Agent Name & Address HARDISON, ROBERT R 539 NE 82 TERR #4 MIAMI FL 33138 US Name Changed: 04/22/2008 Address Changed: 03/24/2009 Officer/Director Detail Name & Address Title STD HARDISON, ROBERT R 539 NE 82 TERR, #4 MIAMI FL 33138 Title D CAULEY, WILLIAM 1331 NE 117 TERRACE ;Entity Name Search fw°SlY[3Y9`lit!t! http://www.sunbiz.org/scripts/cordet.exe?action=DETFIL&inq_doc number=707751&inq ... 1/7/2011 www.sunbiz.org - Department of State Page 2 of 3 MIAMI FL 33161 Title D SEALS, SCOTT 450 NE 82 TERRACE APT 7 MIAMI FL 33138 Title D SHARPE, GEORGE 500 NE 82 TERR, #8 MIAMI FL 33138 Title PD JOHNSON, ALFRED V 911 NE 209 TERRACE MIAMI FL 33179 Title D NOBLES, RANDY 1050 NE 84 TERR MIAMI FL 32138 Annual Reports Report Year Filed Date 2008 04/22/2008 2009 03/24/2009 2010 04/19/2010 Document Images 04/19/2010 -- ANNUAL REPORT j; t :imgg;;im:P,Dt"Rfiarcrra�c., 03/24/2009 -- ANNUAL REPORT �.. jfiew^image,:in;;PR.F;farmat;.- ry 04/22/2008 -- ANNUAL REPORT 1;^;,~Vievrr.inaage:,:in;;PDt".farmat 04/04/2007 — ANNUAL REPORT 1-View;:image in ..... . 07/11/2006 -- ANNUAL REPORT ^;; Vieiruimagin:PDFfiat,radf 02/23/2005 -- ANNUAL REPORT 14, 02/04 /2004 --ANNUAL REPORT ��.....,;1�ieuy�,imag�,in;P.DE:;formai;;,,,,, 01/27/2003 -- ANNUAL REPORT .. »1 ievv imag cin; PQ.;fibrma ;;,-.., •r, 03/28/2002 -- ANNUAL REPORT 03/12/2001 -- ANNUAL REPORT 1f. 01/21/2000 — ANNUAL REPORT ,„,,,.„„„lfiew;imagenin:Di:;:formalr=,,: 07/23/1999 -- ANNUAL REPORT 1. 1 ievv,.image;:in„ED.Elaru�d4,.;;rm; r, 01/28/1998 ANNUAL REPORT (,.,....,,,mttievv,:image:;im;:PDE:tormat,.,..,- •,fi: 01/24/1997 -- ANNUAL REPORT (; ; to ;image n:,PDF;forn;rat,::••-ii image,'in EDF format:: ie�rvaimaga in;;P., 01/20/1995 -- ANNUAL REPORT7;DE'fartnai Note: This is not official record. See documents if question or conflict. Previous on List Next on List Return To List Entity Name Search http://www. sunbiz.org/scripts/cordet.exe?action=DETFIL&inq doc_number=707751 &inq ... 1/7/2011 www.sunbiz.org - Department of State Page 3 of 3 Events No Name History • Home ( Contact us ( Document Searches ( E-Filina Services ( Forms ( Help ( Cooyriaht© and Privacv Policies State of Florida, Department. of State http://www.sunbiz.org/scripts/cordet.exe?action=DETFIL&inci_doc_number=707751 &inq ... 1/7/2011 CITY OFMIAMI DISCLOSURE OF CONSIDERATION PROVIDED OR COMMITTED FOR AGREEMENT TO SUPPORT OR WITHHOLD OBJECTION The City of Miami requires any person or entity requesting approval relief or other action from the City Commission or any of its boards, authorities, agencies, councils or committees, to disclose at the commencement (or continuance) of the hearing(s) on the issue, any consideration provided or committed, directly or on its behalf, to any entity or person for an agreement to support or withhold objection to the requested approval, relief or action. "Consideration" includes any gift, payment, contribution, donation, fee, commission, promise or grant of any money, property, service, credit or financial assistance of any kind or value, whether direct or implied, or any promise or agreement to provide any of the foregoing in the future. Individuals retained or employed by a principal as a lobbyist as defined in Sec. 2-653, and appearing before the City Commission or any of its boards, authorities, agencies, councils or committees solely in the capacity of a lobbyist and not as the applicant, or owners' legal representative are not required to fill out this form. NAME: HOME ADDRESS: CITY: (First Name) (Middle) (Last Name) (Address Line 1)) k (Address Line 2) STATE: Florida ZIP: S.-- HOME PHONE: /O'S `31(--- S -3 U 0 CELL PHONE: a < CI —1 ! `)-(6G FAX: � S 1 _ 6),�'t` EMAIL: BUSSINESS or APPLICANT or ENTITY NAME BUSINESS ADDRESS: c_t(A (Address Line 1) (Address Line 2) 1. Please describe the issue for which you are seeking approval, relief or other action from the City Commission, board, authority, agency, council, or committee. ram" \ X,rt Vt 0 — (.0 VIO V --"-‘0,6 2. Has any consideration been provided or committed, directly or on your behalf, to any entity or person for an agreement to support or withhold objection to the requested approval, relief or actio El YES NO If your answer to Question 2 is No, do not answer questions 3, 4 & 5 proceed to read and execute the Acknowledgment. If your answer to Question 2 is Yes, please answer questions 3, 4 & 5 and read and execute the Acknowledgement. Doc. No.:86543 3. Please provide the name, address and phone number of the person(s) or entities to whom consideration has been provided or committed. Name Address Phone# a. \\,)b. c. 'l` Additional names can be placed on a separate page attached to this form. 4. Please describe the nature of the consideration. k 5. Describe what is being requested in exchange for the consideration. \‘'.-1 ( A ACKNOWLEDGEMENT I hereby acknowledge that it is unlawful to employ Ordinance 12918 and such circumvention shall or civil penalties that may be imposed under disclosure requirement was not fully and timely 1. the application or order, effect; and 2. no application from any considered by the applicable nullification of the application PERSON SUBMITTING DISCLOSURE: OF COMPLIANCE any device, scheme or artifice to circumvent the disclosure requirements of be deemed a violation of the Ordinance; and that in addition to the criminal the City Code, upon determination by the City Commission that the foregoing satisfied the following may occur: as applicable, shall be deemed void without further force or person or entity for the same issue sh 1 be reviewed or board n i piration of a pe od o one year after the or order. '------ signs _, r'_N.,\. . \'-e_./'`^'c4v-Sc—li Print Name Sworn to and subscribed before me this 1 day of ,jQ1r1l,lQ 20 (0 The foregoing was acknowledged before ----PC yC Wei S LiCQ..yl &t_ as identification me by 1 Sen. -\-e rno, c'Z. , who has produced and/or is personally known to me and who did/d' in oath. o Ikv iry, WARP/ Public Slate 0 Merida r Sandra Fames qe �Ex Gommi991an DDB59677 �}nea� Expires02109/2013 STATE OF FLORIDA CITY OF MY COMMISSI N EXPIRES: a(�� (� t Y--icka 'c e.s Print Nadi e Enclosure(s) Doc. No.:86543 Page 2