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i ' M <br /> '� � Sectian�6: <br /> If you h e submiffed an eiedronic payment fior this applic�fion,the transat�an t�firsr�ation number is listed in the following spaoe: <br /> � :onfirm�tion t3umber. �g�'��Q��$ Applic:�tion Nurr�ber: E40492492 <br /> aectio 7: NIA <br /> e you affiitated with any casrpara�ion or limi#ed liahility corr�pany o#her than the corporation or I�ited liabitiiy..company to which <br /> #his application appiies? <br /> Name: FEtN Name: FEIN <br /> Name: FEIN <br /> Sectio 8:CONSTRUCTIQN INDUSTRY AND NON-CONSTRUC�ION;tNDUSTRY LLC MEMBERS ON#.Y <br /> To be ligible for a construction industry exemption ar a non-consfr�acciion timifed liabitity carrtpany exemption,an applic�t must <br /> have e required ownersh�p of the carpora#ion ar fimited liability company. � <br /> 1 a�n a sharehotder owning at ieast ten percent{10�fo)of stack ofi the corporation iisted an this apRl�cation• <br /> Sectio`n 9: . , <br /> t cerfif r thaf any emptayees of the corpor4a#ion oc it�errf6ers af the fisrti#ed iiabiliiy corr�pa[�y listed in Sectian 3 are cavered Eay <br /> workers'compensa#ion insurance. Piease identity:the workers'compensatio�ins�rance carrisr!#�a#cavers any non-exernpt <br /> empto ees. � <br /> Carrie Name: My business does not have any nan�xemp#employees <br /> Se�ti n 10: FRAUD NC3TiCE <br /> A Any persan wha, knowingly and-with intent ta injure,ifefraad,,ar deceive fhe depar�ment or.any employer or emptoyee, <br /> insurance company or,ariy;other person,fites_a Notice of Etec�i6n to be E�cempt:cont�ii�ing any false or rrtisteading <br /> infarmation is guitty of�a=felony of the third d�g�ee:., <br /> B. At#estation of applicant—Sy provid"sng rny nairie below,1 attest that!have.re-acl;�understand and adcnowledge the <br /> fotegoing no#ice_ . " <br /> C. Acknowledge that ti�is No�ice of Etedibn#o be Exempt does not exc�ed limifs fior carporate afficers, including any <br /> affiliated corporations as provided irrSection 440.02, Florida Statutes. <br /> First�iame: Dauglas Last Name: Rogers <br /> Note Tt�e E)ivision has 3Q days ta�review y.our apglicaiion to determine if it meets the eligbility requirements for the issuance of <br /> an e,emptian.The Division wilE either 9ssue a::CierEirt�cate of Election to tie F�cempt or r�atiffy yau that yaur applica�on is incomplete. <br /> Ttte irrision reviews and processes exemptiori applicatians in ft�e orderthey are received. <br /> Fx. :>Ption inforrriation is reflected an#he Praof of Coverage database.tt�e day fo!!ow'sr�g the iss�ance of the exemption.Visit the <br /> Di ' ion's website at:�iftp:/lwww.my�oridacFa_com/wc ta print:yaur certificate. <br /> � ' . , <br /> i � <br /> .� <br />