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<br />. .~.,,~~ N011g~ONWBl::uDIfT <br /> <br />........1[ J~ ......~ f~T T...... n .. - .... f'" -'f ...,....................,............ .,- r1' 1.......-- II'~' - <br />___AI l.ttl'F".... ...,... 'II ~.V......'1I........... ...,_...,.... __01,.. "'r-,.... <br /> <br />SECTION 1: () <br />AppIiaIlt N_~print): ~~ a..~ b,< ~ '\?\-\, \\\ ~ <br /> <br />...................., _....or "'~W.....,...m: ~" I '\\4 <br /> <br />_lIallt's........... <.....1): <br /> <br />SEenOf' 2: I.......... ....._...... -. <Y- .... cIIeck...,....... .......): <br />CONSTRUC11ON IND1JSTRY{UI nE RBQ1JIIIm) <br />o Ofticerof. CoIpcnIion (TdIe): -OR. ~ M__ of. r llnlt.M u.biIiIy Compmy (LLC) <br />NON-cDNSTJlUCI1ON JM)1)$I AY. (NO nz DQUIRED) <br />o OftIaarofa CoIpandaa (TidIl): ) <br />1ba Divisima wIl KlCqlta ....,...... .c:aa.'s........ cIcdI.. ~.... payable to'" DFSWC ~ T... Fund. <br />All oftIeer _ ..... a.. Ptorida ......... ...... .. bile.'" ..... dill <br />_cnOJlf 3. To be eliaible far.. .-~IIi.nq. die carporaIiaD oCwhich you aN" ofticer or Ibe IiaIiIed IiItJiIty ClOIIIpIIIY orwhida <br />you IN . JRaIIber IIIUIt be ....... with the Florida Division ofCorpcndcas. For .........applyiDa.... oJBcer of. <br />~,.,u1llUlt belillDd...oftbI' oflllo CarpcnIiae wiIb the FlaridaDiviliaa ofCorpcndcas. Lilt die document <br />awnbel' (ctr-Mftt DIIIIIbIIr sboWD CIIl"'" Aaaual RIlport) OIl file with die Florida DlYiliaa ofCorparations. <br /> <br />I 16o~~ <br /> <br />SJCI'ION 4.. ~ eXCIIIpdaa appIicatioa...... 0D1y 10 1110 I!SD!!I si8J1ia11hD lppIicItioP. tile CorpantianILLC tbat it JisIecI <br />below. and Cbe scope of......~ ~ <br />N_ofCorpcnliOllor~: ~~ ~~~~~ _._ . FEIN:~"'-\~ <br />Business N.ae: ~ ~ L ~\Q6_~ PhaGe: ( ) <br />...........-UII'~__IIOMG_d..... .u.-....dIllAllaCAIW <br />Business MaiJinc Addnras:....:J. ~ 0 ~ O~ ~ \ - <br />.......~..--- <br />CIty: Se~~ \U!A... StaIe:;:L Zip: ~ ~~g~ County: ~,,~~~"- <br /> <br />ScopeofBusineslorTndeofApplicant: I. \.\oDeD ~~..\." 2. 3. <br /> <br />SECI'ION 5. List all cedified or ~ ""- isIued pUISUIIIIt to CbapIer 419. '.S. held by 1110 ....ana... die CCldifted or <br />,..... Ucease ......... bIId by 1IIe qUIIifier fix' die c:orponIion or u.c IisIed CIIlIbis IIJIPIIcaIioa of wIIich tile applkant is a <br />CCNpclllleofticer: <br />!I&L:a:a()N 6. Does die CCIUIIIy or ~ .......,... bI.BiBesi is 1.-1 ftlII1Ift" occu"".-_. .... tbr JOUr' bIBiness? <br />Yes 0 No or YU,.to COPY OW.to CIJIUIDiT OCCUPAtJONALUcmSE MUST 8& ATrACUm. <br />SECTION '7... AN you..... witb .., CCII6~.aiGn (including UC) 0lhIr 1ban tbo ~.riGD Q~~Idi.. LLC) 10 which tbis <br />appIbdon 1ppIias? DYes'GJoHo <br />II' YES," ~.6.tm LIST'" NAME(s) AND JI'EJN(.)O' no: An'ILIATBD COltPOllA'nON(I) OR LLC(a): <br />NAID: nJN: <br />SI'.CI"ION" (()VIII' ClOIfIOIlIIiaa or u.c is.,.... ill dID CCHDtrucIian inIIuIDy. you .....cwido Ibe JeqUired plOOf of <br />owuenbip in ... ClOIpJI1ItioD ... lJ..C. <br />A. To be eligible fOr a CDIIIIIUction iaduslry campCion . an ofticer of a COI)ICXIdion. the IIpplbnt must be a sMNholder. <br />awaiDa- ...lCMof.....aof1blCGI~.....i. A COPY O' A STOCItcaTlftCATE EVIDENCINGTIIB <br />UQUJRmOWNJ:RSIIIPMUST.. ATrACHED. <br />B. To be eJiaible far a c;aastnICtioD UMUIIy CUIIIpdon .. member of aliJDiIed IiIbWty '*DpM)'. tbe appJ~ musr <br />codrm ownmbip of.... 10% oCtile ~..,. TBB REQOJRED OWNDISII BY <br />PRODUcnON O.IJOCUMDITATION UPLECflNG.... uoumm <br />SUBMllTlNG A BrAT&IIBNT A:I-'..~G TO 'l1IE REQOJRED OWN <br /> <br />MAR 13 <br />'I'IIm Al'JlLlCAlION ISQJNTINUED ON PA.GE 2 <br />1MC_.......___1O_.......-~_ 8UREf'~ <br /> <br /> <br />€0/c;0 38\;td <br /> <br />38I^~3S ~3~OlSn8 8M <br /> <br />USc;lc;60S8 <br /> <br />lp:60 800c;/Lc;/€0 <br />