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03 -17 -2010 <br /> ��y - Ef t <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: 05/02/2010 EXPIRATION DATE: 05/01/2012 <br /> PERSON: FAUSTRUM FRANK J <br /> FEIN: 593016581 <br /> BUSINESS NAME AND ADDRESS: <br /> TAMPA SIGN INC <br /> 8616 N HIMES AVE <br /> TAMPA FL 33614 <br /> SCOPES OF BUSINESS OR TRADE: <br /> 1- GENERAL CONTRACTOR 2- SIGN INSTALLATIONS /MAINTENANCE <br /> IMPORTANT: Pursuit 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 roller tkis chapter. Pursue to Chapter 440.05(12), F.S., Certificates of electioa to be exempt-.. apply only within the <br /> scope of the business or trade listed ea the notice of electioa to be exempt. Pursuant to Chapter 440.05(131, F.5., Notices of election to be exempt and certificates of <br /> electioa to be exempt shall be subject to revocation if, at any time after the filing of the Notice er the issuance of the certificate, the person named en 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 1allure of the person <br /> named on the certificate to meet the requirements el this section. <br /> QUESTIONS? 0150) 413-160. <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 WOR CERS' COMPENSATION j� + F 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 ? ;: p L under this section may not recover benefits or compensation under this <br /> WORKERS' COMPENSATION LAW ? D chapter. <br /> EFFECTIVE 05/02/2010 EXPIRATION DATE: 05/01/2012 Pursuant to Chapter 440.05(12), F.S, Certificates of election to be <br /> PERSON: FRANK J FAUSTRUM H exempt.. apply only within the scope of the business or trade listed on <br /> FEIN 593016581 R the notice of elipri to be exempt <br /> BUSINESS NAME AND ADDRESS: E Pursuant to Chapter 440.05(13), F.S., Notices of election to be exempt <br /> TAMPA SIGN INC and certificates of election to be exempt shall be subject to revocation <br /> 8616 N HIMES AVE if, at any time after the filing of the notice or the issuance of the <br /> TAMPA, FL 33614 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- GENERAL CONTRACTOR 2- SIGN INSTALLATIONS /MAINTENANCE Section. <br /> 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 />