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; 1�!1 j 100% <br /> �`iUF'�2��y <br /> �T�. S; ?e. <br /> q 't�n` <br /> ,��'+m..�'• <br />� JEfF ATWATQ2 <br />' CHIEFFlNANCIALOFFlCEA STATE OF FLORIDA <br />� DEPARTMENT OF FINANCIAL SERVICES <br /> DIVISION OF WORKERS'COMPENSATION <br /> **CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS'COMPENSATION LAW** <br /> CONSTRUCTION INDUSTRY EXE�APTION <br /> This certifies that the individual listed below has elected to be exempt from Florida Workers'Compensation law. <br /> EFFECTIVEDATE: 4/1/2015 EXPIRATIONDATE: 3/31/2017 <br /> PERSON: SULLIVAN TIMOTHY H <br /> FEIN: 473516942 <br /> BUSINESS NAME AND ADDRESS: <br /> SULLIVAN REMODELING AND SMALL JOBS LLC <br /> 35145 ADA AVE. <br /> ZEPHYRHILLS FL 33541 <br /> SCOPES OF BUSINESS OR TRADE: <br /> CARPENTRY <br /> INSTALLATION OFCA <br /> Pursu ant to Chapter 440.05(14),F.S,an o flicv of a corporatian who elects exemption from this chapter by filing a certificate o(eleaion und cr this section <br /> may notrecaverbenefitsorcompensationundvthisdiaprer.PUrsuanttoCh�tv440.05(12),F.S,Certdiptesofe6ea�ontobeexcmpt. applyonty <br /> with in the scope of the busin ess or trade listed o n the notice of election to be exempt.Pursuan t to Chapter A 40.05(13),F.S.,Notices ol Mection to he <br /> r,�cmv��dcMiliwtesoleleaiontobe�empt shaAbesubjetttorevowtionif,atanytimeaftertheli6ngoftAenoticeortheisuanceolthecertificat0 <br /> th e person named on thc notrce or artNicate no longer mcets the requiremcnts of this seaia n lor issum ce of a cenifinte.The department shatl«voke a <br /> DFS-F2-0WC•252 CEFiTI FICATE OF ELECTION TO BE EXEMPT REVIS m OS-13 QUESTIONS?(B50)413�7609 <br />