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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 { 3 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 certificate of election <br /> CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA "a 'j L p p y g <br /> WORKERS' C LAW � under this section may not recover benefits or compensation under this <br /> D chapter. <br /> EFFECTIVE: 06/05/2009 EXPIRATION DATE: 06/05/2011 Pursuant to Chapter 440.05(12), F.S., Certificates of election to be <br /> PERSON: RUSSELL R JOHNSON H exempt... apply only wituin the scope of the business or trade listed on <br /> Ism , 943470020 E the notice of election to be exempt. <br /> GOLDEN RULE PLUMBING INC ' ^" <br /> 23011 BOWMAN RD 4 'r ({suant to Chapter 440.05(13), F.S., Notices of election to he exempt <br /> if, af@rtiffice) f elution to be exempt shall be subject to revocation <br /> SPRING HILL, FL 34610 s A <br /> certificate, the per n na f' 'n of the notice or the issuance of the <br /> m�� 9 <br /> the requirements of this section the notice or <br /> the no longer meets <br /> department shall revoke a certificat)r issuance of a certificate. The <br /> SCOPE OF BUSINESS OR TRADE: person named on the certificate to 1 at any time for failure of the <br /> . <br /> 1- CERTIFIED PLUMBING CONTRACTOR section. 'eet Hy requirements of tLis <br /> a <br /> QUESTIONS? (850) 4 r3 4z <br /> CUT HERE <br /> * Carry bottom portion on the job, keep upper portion for your records. <br /> • <br /> IWC -252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 09 -06 <br /> o STATE OF FLORIDA ;` ' � ; , 2 : <br /> ,,D'DE T 'O BUS'iI SS`ro D <br /> c' 170.' - t tl� i 0 813 <br /> CER ' / i, � * . i .,.w rte.7uy! & i 7 , �Ca ,, <br /> JORNS1 y,, } ''I Jr' aP s S 1 ) <br /> COLD 1 1 @ i! I74 / f' "°&a <br /> C7IR , s,,, ,,, rr , . _ 'y ... k � y, .'' t ).„1;-!* ' Q ) `a ,s' . <br /> xxpir --P . - 1 n al r t �rA� '. , 1 , 20,`2 `L x»6 0 .:::.; ';, <br /> . 3 �' �kaa . . <br />