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<br />Aug 08 08 09:30a <br /> <br />Lisa Booker <br /> <br />8137837891 <br /> <br />p.2 <br /> <br /> <br />04-17-2008 <br /> <br />ALEX SINK STATE OF FLORIDA <br />CHIEF FINANCIAL OFFICER DEPARTMENT OF FINANCIAL SERVICES <br />DIVISION OF WORKERS' COMPENSATION <br /> <br />* * CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS' COMPENSATION LAW * * <br /> <br />CONSTRUCTION INDUSTRY EXEMPTION <br /> <br />This certifies that the individual listed below has elected to be exempt from Florida Workers' Compensation law. <br /> <br />EFFECTIVE DATE: 04/17/2008 <br /> <br />PERSON: BOOKER <br />FEIN: 204474712 <br /> <br />BUSINESS NAME AND ADDRESS: <br />BIIII LLC <br />39838 STEWART RD <br />ZEPHYRHILWS FL 33540 <br /> <br />EXPIRATION DATE: 04/17/2010 <br /> <br />LARRY <br /> <br />W JR <br /> <br />SCOPES OF BUSINESS OR TRADE: <br />1- MOB! LE HOME TIE DOWN (8400) <br /> <br />IM.ORTANT: "'suant 10 Daple. 440 . Q51141. F.S~ an of/jeo. .f . e.rpora1i.. wh olocu ......llon from l~is eb.p10. bV lilill9 . eerliliale 01 Ilecli.. "_1' Ihis <br />slldi_ m." .., rec:oul .....IIIs. .r co.......... ..... .his c.....er. Pune...t Ie Clllprlf .48~a5CI2.L f.S.. Cenilir.es D' cl.'U_1I ID be ..'WI,I... Ipply Dnly willlin tile <br />ICDpe .. II. ''''IISSO' Ind. 1i1l.4 01 .h ...ice or .ledi.. 'D b. ._L 'urs."1 10 ClIoflOf 440.154131, F.S.. NOliees 01 .leeUDo '0 bl e......1 .._ cor:i'ical.s 01 <br />oIleUOI ... H ..e....' ...11 h lallj..' I. '...e....n iI, "' IOY Ii.. .r.Of ... II Ii", DI I.. llDliee or I.. i.I...c. .r lh clnil;call. '.e person n..... on lh '.Iitt or <br />clrtiliclI. wa ...ger 11I"'$ the relluil....11S ., Ibis SKli_ tor illUllCe 01 . cI"ilicale. TIle d.p......enr 'llll uvoke I ceni'.cal-e II any titRe for f.ihre of Ibe pcrs.. <br />..._ OIl t" tellihClle to meel die r.q..i.....ts of lIli'S _ctiM. <br /> <br />DWC-252 CERTIFICATE OF ELECTION TO BE EXDJI>T REVISED 09-06 <br /> <br />QUESTIONS? 185m 41]-1609 <br /> <br />PLEASE CUT OUT THE CARD BELOW AND RETAIN FOR fUTURE REFERENCE <br /> <br />STATE OF FLORIDA <br />DEPARTMENT OF FINANCIAL SERVICES <br />DIVISION OF WORKERS. COMPeNSAnoN <br />CONSTRUCTION lNDU$TRY <br />CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA <br />WORKERS COI'M9SATION LAW <br />EFFECTIVE: 04/17/2008 EXP1RATlDN DATE: <br />PERSON: LARRY W BOOKER .JR <br />FEIN: 204474712 <br />BUSINESS NAME AND ADDRESS: <br />IIMI lLC <br />31838 STEWART RD <br />ZEPHVIl..lS. FL 33540 <br /> <br />~ <br />W' <br /> <br />F IMPORTANT <br /> <br />o Pursuant to Challler 440.051141. F.S.. an officer of a corpor~ion who <br />elects exemption from this chapter by filing a certificate of election <br />Lunder 1his section may not recover benefIts 0' compensation unlier this <br />D chBpter. <br /> <br />H Pursuant to Chlpter 440.05(121. F.S.. Certifica1es of election 10 be <br />exempt.. IIlplV onlv within the scepe of lIle business or trade listed on <br />E the notice of election to be exempt. <br />R <br />E PurSll8llt to Chapter 440.05(131, F.S.. Notices of electior. to be exemPt <br />anti certificates of electien 1e be exempt shall be subject to rel/Oc/ltien <br />if. lit ...y lime after 1he filing of the nOlice or tile iSSuance of the <br />certificate. Ihe person named on the notice or certifiCllte no longer meets <br />the requirements of this seetion for issLlllnce of a certifiCllte. The <br />department shall revoke a certifica1e lit any time for failure of the <br />person named on 1he certificate to meet the requirements of thIS <br />section. <br /> <br />04/17/2010 <br /> <br />SCOPE OF BUSINESS OR TRADE <br />,. Mone HONE TIE DOWN 16400) <br /> <br />QUESTIONS? 185D) 413-16D9 <br /> <br />CUT HERE <br /> <br />· Carry bottom portion on the job, k_p upper portion for your records. <br /> <br />OWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 09-D6 <br />