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fit^ ynl 04 -02 -2010 <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: 04/02/2010 EXPIRATION DATE: 04/01/2012 <br /> PERSON: GRAY SAMUEL N <br /> FEIN: 271187800 <br /> BUSINESS NAME AND ADDRESS: <br /> FAITHBILT CONSTRUCTION INC <br /> 4101 WINDTREE DR <br /> TAMPA FL 33824 <br /> SCOPES OF BUSINESS OR TRADE: <br /> 1- CERTIFIED BUILDING CONTRACTOR <br /> IMPORTANT: Pursuant la Chapter 440 . 061141. F.S.. an officer of a corporation who elects exemption Irom This chapter by filing a cerlil icate of election under this <br /> section may not recover banal its or compensation under this chapter. Pursuant to Chapter 440.051121. F.5., Certil icales al election to be exempt... apply only within the <br /> scope al the business or Trade listed on the notice of election to be exempt. Pursuant to Chaplet 440.051131, F.S., Notices of election to be exempt and cerlllicetes of <br /> election la be exempt shall be subject to revocation if, at any lime Alter the filing of the notice or the issuance of the celltlicate, the person named on the notice or <br /> certilicate no longer meets the requirements al this section for issuance of a certificate. The department shell revoke a cerlilicale el any line ter failure al the person <br /> named on the certilicate to meet the requirements of This section. <br /> QUESTIONS? (850) 413 -1609 <br /> OWC -252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 09 -06 <br /> • <br /> PLEASE CUT OUT THE CARD BELOW AND RETAIN FOR FUTURE REFERENCE <br /> STATE OF FLORIDA IMPORTANT <br /> DEPARTMENT OF FINANCIAL SERVICES F <br /> �,, ��°• t ' <br /> DIVISION OF WORKERS' COMPENSATION r7Ti1 Pursuant to Chapter 440.05(14). F.S., an officer of a corporation who <br /> CONSTRUCTION INDUSTRY elects exemption from this chapter by filing a certificate of election <br /> CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA ' y r L <br /> WORKERS' COMPENSATION LAW under this section may not recover benefits or compensation under this <br /> D chapter. <br /> EFFECTIVE: 04/02/2010 EXPIRATION DATE: 04/01/2012 Pursuant to Chapter 440.05(12). F.S., Certificates of election to be <br /> PERSON: SAMUEL N GRAY H exempt... apply only within the scope of the business or trade listed on <br /> FEIN: 271187800 E 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 /> FAITHBILT CONSTRUCTION INC and certificates of election to be exempt shall be subject to revocation <br /> 4101 MODULES DR I f, at any time after the filing of the notice or the issuance of the <br /> TAMPA, FL 33624 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 /> I • CERTIFIED BUILDING CONTRACTOR section. <br /> QUESTIONS? (850) 413-1609 <br /> CUT HERE <br /> *- Carry bottom portion on the job, keep upper portion for your records. <br /> OWC -252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 09-06 <br /> • <br /> • <br /> • <br /> • <br />