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07/13/2006 23:23 7273757332 PAGE 03 T~t & ll--WJ NOTICE OF ELECTION TO BE EXE~ ~rsowiJ!DJ Please refer to tlte enclosed instrudions before completblg tIIis fonn. JUl 1 3 2006 SECTION. ): I am applying for ~emptjon as a (please check only one box in this section): TAMPAMPUANCE CONSTRUCTION INDUSTRY "C~PO~TE <?BICER" ($50 APPLICATION FEE REQUIRED) 9l Officer.of a Coxporation (Title): rFlJ!.:> i T:).l!,rJ. ( ) -OR- 0 Member of a Limited Liability Company (LLC) NON-CONSTRUCTION INDUSTRY "CORPORATE OFFICER" (NO FEE REQUIRE~ o Officer ora COIJloration (Title): ) ~ An officer ejecting au e:l:emption under chapter 440 Florida Statutes is not entitled to bene SECTION 2. To be eligible for an exemption, the corporation of which you are an officer or the limited you are a member must be registered with the Division of Corporations of the Department of State. For applic' officer of a corporation, you must be listed as an officer of the Corporation with the Division of Corporations of State. Please lis..t....the registration number c.docU9lent number shown on your UnifODl) Business Report) on filc with the Corporations. t::. 't If 0 00 0 ~ J.. 3. X. SECTION 3. This exemption application applies only to the Derson signing the application, the Corporation/LLC that is listed below, and the scope ofbusinesl oli !rz1~li$te.r!: I/). . 127. Corporation OJ' LLC Name: 1:t.~4n1ltr' /,.(J"fV~~ .IPkJN:SCJ .33~'1Z2>TeJephonc: l.(~lJ~i 'f9".3. I BusinessMailingAddress:[1531 P~/ZA:fn11> DIZ. City:OOOSA State: & zip:3~ County: lASe.[) . &1I1t...t;;JIrJf. Scope of Bns1ness OJ' Trade of Applicant: 1. ~ 2. 3. 4. SECTI. ON 4. Please list aU ~ed or registered licenses issued to the applicant pursuant to Chapter 489, F.S. (Contractor's License)--.C:..e.C O~ O~I . SE ON. i~. D.oes the county or municipality in which your business is located require an occupationa1license for your business? DYes .No IF YES, A COPY OF A CURRENT OCCUPATIONAL LICENSE MUST BE ATTACHED. SECTION 6. Axe you affiliated with any corporation (including LLC) other than the corporation (including LLC) to which this application ~lies? o Yes ~No IF YES, PLEASE LIST THE NAME(s) AND FEIN(s) OF THE AFFILIATED CORPORATION(s) OR LLC(s): NAME: . _.. ... FEIN: SEC'IION 7, If your corporation or LLC is engaged in the construction industry, you must provide the required proof of ownership in the corporation or LLC. A. To be eligible for a construction industry c:xemption as au. officer of a corporation, the applicant must be a shareholder, owning at lea..~ 10% of the stock oftbe corporation. A COPY OF A STOCK CERTIFICATE EVIDENCING THE REQUIRED OWNERSHIP MUST BE ATTACHED. B. To be eligible for a construction industry exemption 8S a member of a limited liability company (LLC), the applicant must confIrm ownership of at least 10% of the company. THE REQUIRED OWNERSHIP MAY BE ESTABLISRED BY PRODUCTION OF DOCUMENTATION R.EFLECTJ.NG 1llE REQUIRED OWNERSHIP, ORBV SUBMITTING A NOTARIZED STATEMENT ATTESTING TO THE REQUIRED OWNERSBIP. SECTION 8. FRAUD NOTICE A. Any penon who, knowingly and with intent to injure, den'and, Or deceive the department or any employer or employee, in~lu'ance company or any other person, files a notice of election to be eJ:empt containin~ any false or misleading information is goUty of a felony of the third degree. D. =- .hP~ z.; aOW'l lIlat I .... r.... ..d.....ODd ODd .-...ledge th. foregoing ~ ~SIGNATVJU!: OF APPLICANT . tHIS Af!f!LlCA TION IS CONTINUED ON THE REVERSE SIDE . owe 25D, NOTICE OF ELECTION TO BE EXEMPT - REVISED 312D04 TV-2