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''`` "' 11 -20 -2009 <br /> • ALEX SINK STATE OF FLORIDA <br /> CHIEF FINANCIAL OFFICER DEPARTMENT OF FINANCIAL SERVICES <br /> DIVISION OF WORKERS' COMPENSATION <br /> * * CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS' COMPENSATION LAW * * <br /> CONSTRUCTION INDUSTRY EXEMPTION <br /> This certifies that the individual listed below has elected to be exempt from Florida Workers' Compensation law. <br /> EFFECTIVE DATE: 11/20/2009 EXPIRATION DATE: 11/20/2011 <br /> PERSON: PIERCE MITCHELL 0 <br /> FEIN: 593664637 <br /> BUSINESS NAME AND ADDRESS: <br /> QUALITY GARAGE DOOR SERVICES INC <br /> 116 SOUTH PARK AVE 30/-26.9- h 3 G I ' 9 <br /> TITUSVILLE FL 32796 <br /> jz /— z (,q7-7Y <br /> SCOPES OF BUSINESS OR TRADE: <br /> 1- REPAIR SERVICE 2- CERTIFIED RESIDENTIAL CONTRACT <br /> 3 - GARAGE DOOR INSTALLATION <br /> IMPORTANT: Pursuant to Chapter 440 . 05(14), F.S., an officer of a corporation who elects exemption from this chapter by filing a certificate of election under this <br /> section may not recover benefits or compensation under this chapter. Pursuant to Chapter 440.05(12), F.S., Certificates of election to be exempt... apply only within the <br /> scope of the business or trade listed on the notice of election to be exempt. Pursuant to Chapter 440.05113), F.S.; Notices of election to be exempt and certificates of <br /> election to be exempt shall be subject to revocation if, at any time after the filing of the notice or the issuance of the certificate, the person named on the notice or <br /> certificate no longer meets the requirements of this section for issuance of a certificate. The department shall revoke a certificate at any time for failure of the person <br /> named on the certificate to meet the requirements of this section. <br /> QUESTIONS? (850) 413 -1609 <br /> DWC -252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 09 -06 <br /> PLEASE CUT OUT THE CARD BELOW AND RETAIN FOR FUTURE REFERENCE <br /> STATE OF FLORIDA IMPORTANT <br /> DEPARTMENT OF FINANCIAL SERVICES ►'' <br /> DIVISION OF WORKERS' COMPENSATION 0 w t F to Chapter 440.05(14), F.S., an officer of a corporation who <br /> CONSTRUCTION INDUSTRY � . O elects exemption from this chapter by filing a certificate of election <br /> � <br /> CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA . • • ` � e� L under this section may not recover benefits or compensation under this <br /> WORKERS' COMPENSATION LAW �^ <br /> D chapter, <br /> EFFECTIVE: 11/20/2009 EXPIRATION DATE: 11/20/2011 Pursuant to Chapter 440.05(12), F.S., Certificates of election to be <br /> PERSON: MITCHELL 0 PIERCE H exempt.. apply only within the scope of the business or trade listed on <br /> FEIN: 593664637 R the notice of election to be exempt <br /> BUSINESS NAME AND ADDRESS: E Pursuant to Chapter 440.05(13), F.S., Notices of election to be exempt <br /> QUALITY GARAGE DOOR SERVICES INC e exem P <br /> and certificates of election to be exempt shall be subject to revocation J � <br /> 116 SOUTH PARK AVE if, at any time after the filing of the notice or the issuance of the <br /> TITUSVILLE, FL 32796 certificate, the person named on the notice or certificate no longer meets <br /> the requirements of this section for issuance of a certificate. The <br /> department shall revoke a certificate at any time for failure of the <br /> SCOPE OF BUSINESS OR TRADE: person named on the certificate to meet the requirements of this <br /> 1- REPAIR SERVICE 2- CERTIFIED RESIDENTIAL CONTRACT section. <br /> 3- GARAGE DOOR INSTALLATION QUESTIONS? (850) 413 -1609 <br /> CUT HERE <br /> * Carry bottom portion on the job, keep upper portion for your records. <br /> DWC -252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 09 -06 <br />