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<br />STATE OFFLORIOA <br />DEPARTMENT OF INSURANCE <br />OfVtSIONOFWORKERS' COMPENSATION <br />CERTFlCA TE . OF EXEMPTION.FROMfLORtDA WOAK.ERS'COMPENSATfQN lAW <br /> <br />1.2-06-2002 <br /> <br />CONSTRUCTION INDUSTRY EXEMPT!ON <br /> <br />This certifies that theiodlviduallisted belo.w has elected to be exempt from <br />Florida Workers' COIl1PCJn$8tion law , <br /> <br />EFFECTIVE <br />PERSON <br /> <br />12/07/.2002 <br /> <br />EXPJRA TION DATE 12} 06 / 2004 <br /> <br />HEP.Klib.~EZ <br /> <br />JUN.!OR R <br /> <br />S~N <br /> <br />072~.64 -::\42S <br /> <br />FEW <br />BUSINESS <br /> <br />59321293J <br /> <br />HEP.NANDEZ JtJlUOR HEATlNG it COOL um <br />-4521 W KNOLLWOOD ST <br />'I'A.."1PA F'L:5 3 614 <br /> <br />NOTE: Pursuant to Chapter 440, 1(H1},{g), 2.LS . a so~prollrietor. pattner, or an <br />offfettr -of. '" CVJ.V4KilIlluil '.1lIrhu .Cluct~ eAUlJ~tiun (nn.. tI~nul ide. Wo.L'OO. .t;..' <br />COmpen$tltion Law. mav not recovel" benetitt or. eompenution under Chapter 44 () , <br /> <br />NEASE cm our HtE <br /> <br />lirnil1ID:l <br />an .~4-3m <br /> <br />J~:t.f. <br /> <br />CARD RHOt! <br /> <br /> <br />_1 <br />. , ~ <br />. ."IF <br />..10 <br />tL <br />io <br />I <br />j <br />IH <br />1 <br />~E <br />1 <br />In <br />IE <br />J <br />I <br /> <br />AND &tTAIH FOR fUTURE RErfRFNCf <br /> <br />r^WNN"'~ .. . . <br />.!' lOTAlI:OF' 1-lORl)A <br />. na>AA1'MENt OJ. ~AH::f <br />f Ql'1lSOi o;WOA!WlS' COlW"tNSATIOf. <br />r CONSTAOCTlON N:lUSTRY <br />, <br />i ""')'<'l'~1I'1" (~t!'~_I'I\_t'l..OIl.lDA <br />l WOIU(EW-> COt.ft:HSA TlOtLLAW <br /> <br />f EFFECTIVE' <br />i EXPlJiATION <br />iPEftSON <br />jSSK <br />ffflN <br />iUusrNESS <br />I <br /> <br />....:<:""'-'...~Ao,"\ <br />?Jl~l; t.;f~i.- <br /> <br />fi.-jE' ~~wt(c\i;:~ lKf{;H;\l,~. LL <br />~ -$:-* :'~~i~t::t. r1~~.. ~~~ ~ff~.~'d 1:". U1}::tl1.~~ <br />:ri~_- m.-n tnmtbt ftc~: "::';1 f1itij1 \'n~fr$; -C~u. <br />l~ nr. mt 1*~Ot W'~fu$V' wq~mitt\:;; '$!~' C~W <<~ <br /> <br />llf~':1J-:~ <br /> <br />Sill'12.S!1 <br /> <br />~Jl!}:Z J'Ji,~~Tr;11 coo <br />uz: wmtuvrow. so; <br />lAir:' <br /> <br />R 13m <br /> <br />CUT HERE <br /> <br />· Carry bottom portion 01'1 the Job, ~ upper portion for your records. <br /> <br />'", _._. J.~ .."'..,.>_.....'.e_._"~_ <br /> <br />~. I <...~'"""'............... <br />