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01/08/2008 14:33 7273431422 '\). J~ l)' ~ 't'j, ~'l\ FIRE SYSTEMS PAGE 01 .' . ~Q". '-- 12-14-200' ALEX SINK STATE OF FLORIDA CHIEF FINANCIAL OFFICER DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORI(ERS' COMPENSATION * * CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS' COMPENSATION LAW * * CONSTRUCTION INDUSTRV EXEMPTION This certifies that the individual listed below has elected to be exempt from Florida Workers' Compensation law. ,~ re,~~, ~~ \,0 ~ EFFECTIVE DATE: 12/14/200' EXPIRATION DATE: 12/13/2009 e~ ~ if, Db PERSON: HOCH KEVIN J o''J~ S \ ~ \.... ~ FEIN: 200640754 , ~ ~ 11 crt BUSINESS NAME AND ADDRESS: 'v FIRE SYSTEMS INC \ 2824 56TH ST N SAINT PETERSBURC FL 33710 SCOPES OF BUSINESS OR TRADE: 1- FIRE EXTINGUISHER SERVICE IMPDRTANT: Persa'nl" CRlp/.' uo . 051141. F.S.. .n Dllieer D' . corponUu who .'ects exelllpli.. "'''' Ihls ch.ple, by liIing . cc"iliutn .r ,llcUon und.r lhi! secll.. III.Y .ot r.caver b...'ils If c'''''''.'.llo. e.der lIIi. "eple,. P".......I 10 Ch.oler 44D.OSlTzl. f.S., C.nlff..,.. .1 .1."".. t. h. .....', .,ply ...11' ..'11I1. Ihe leepe .1 tile busl...> or If,'e IISfe' In 1"- noUn or el.ell.. II Ite n...,.. PiorsPlol 10 Chlpl.r 440.0&H31, f.S., Nollces af .I.ello. II b. IItlllpl ... e"tlflcll81 af tle.li.. 10 b. .Jre.pl sh.1I be subjecI t. ,eVentl.. If, .t ny II.. alter the 'iling 0' Ihe nallce Dr /h. iSh..ce ., 'h. conlflclre, llIe penon ..... In llIe .'Un Dr c.rliliul. " looger "'eels die r.""lr...IltS of ",I~ S""on for Iste.nc. 0' . certi'iest.. n. 'epltllllenl ..11 ,.vele n c"rtl/lcl'e .1 '.Y Um. for 'Iilore D' IRe P.,50. named In Ibe .ertl/lcl'o 10 lleel Ih. r.o.i,.",e..s el 'his netl... DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 09-06 QUESTIONS? f8S01 413-1609 -.-.--------..______.............____._..4..........0y.0.........._...........__~_..~~~_:'________._u,...__ ....~---.......".. 0"'- PLEASE CUT OUT THE CARD BELOW AND RETAIN FOR FUTURE REFERENCE STATE OF FLORIDA DEPAATMENT OF FINANCIAl. SERVICES e DMSION OF WORKERS' COMPENSATION CONSTRUCTIDN INDUSTRY CERnFlCATE OF ELECTION TO BE EXEMPT FROM FLORIDA , " , WORKERS' COMPENSATION LAW trrCCTIVE 12/1./200., tXl"lltATION DATI!; 12/13/200. PERSON: KEVIN ~ HOCH FEIN: 200640754 BUSINESS NAME AND AODRESS: F IIIE SYSTeMS INC 2824 56TH S1 N SAINT pn~RSBl1FlC, n 33710 SCOPE OF BUSINESS OR TRADE: 1- FIRE Ell:T1NGUISHER SERVICE ~ F IMPORTANT PursUlllt to ChaPter 440.051141. F.5.. an officer of 8 l:orlloration who o elects exemption from this chapter by filing II l:ertifil:llte of ellction l under this sedion may not rel:over bene"its or compensation under this o chapter. H Pursuarrt to ChIPter 440.05(12), F.S.. Certificates of election to be E exempt.. applV only within the scope of the business or trade listed on the notice of election to bl exempt. ~ R . E Pursuant to Chapter 440.051131, F.S., Notices of election to be ex empti' and certificates of elel:tion to be eJlempt shall be subject to revocation if. at any tilll!! ah!!r th!! filino of th!! Itoti!::!! 0' thl! is!lullftu nf th" certificate. the plrSon nllned on the notice or certHicate no longer meets the rellulremellts of this section for issUlll1ce of 0 certificate. The deplrtment shall revoke II certificate at any time for failure of the person named on tile cenificate to meet tile requiremellts of tnls section. QUESTIONS? (85DI 413-1609 CUT HERE .. Carry bottom portion On the job, keep upper portion for your records. DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 09-06