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• <br /> PLEASE CUT OU7 CARD :BELOW AND RETAIN FOR FUTURE REFERENCE <br /> 4 <br /> IMPORTANT <br /> _M „*1 _\; 4 „e, F Pursuant to Chapter 440.05(14). F.S., an of liter of s ,e4rmorotion who <br /> "'nN \ f "`�°'•� O elects exemption from this chapter by filing a certificate of election <br /> limurner ; Rxt9w1 T PTPROMPLORIDA _ o a L under this section may not recover benefits or compensation wider this <br /> . 01/211/200e EXP. XRAT:ION DATE: 01/20/2011 Pursuont to Chapter 440.06112). F.S., Certificates of *Nation to be <br /> 11RVIS ,PULVORD H exempt.. apply only within the scope of e business err trade listed on <br /> E t the notice of election to be exempt. <br /> so1272 R <br /> dot AND ADDRESS: E Pursuant to Chs too 440.05(13), F.S. Notices of election to be exefapt <br /> let R •" TWno0FUN a eol$TRUCTwri etc and certificates of election to be exempt shall be subject to revocation <br /> fast t>� <br /> yp► most*. 4 i if, at any time after the filing of the notice or the issuance of t <br /> certificate, the person named on the notice sr certificate no 4enger meet <br /> aTrR - the renuivenlents of, this section for immense of a certificate. The <br /> department shell revoke • certNlcae at any time fur failure of the <br /> 1�,,_ e <br /> SS OR person named on the certificate to meet the ragndrancMs of. WMs <br /> �'`wF t 2- CERTIFIED ROOFING CONTRACTOR section. <br /> QUESTIONS? SSOi 413 - ?$0S <br /> `......•/'.- <br /> ....' ` CUT HERE <br /> *Carry bottom portion on the job, keep upper po for your records. <br /> EIWt ATE OF ELECTION TO DE EXEMPT REVISED 09 -06 <br /> s ' :' e,- <br /> r' y ` <br /> ; 'r + t J • <br /> 01-30-2009 <br /> 'Q. <br /> 5°K STATE OF FLORIDA <br /> � dtcui,o DEPARTMENT OF FINANCIAL SERVICES <br /> DIVISION OF WORKERS' COMPENSATION <br /> fl it CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS' COMPENSATION LAW * * <br /> CC CTION INDUSTRY EXEMPTION <br /> J* sties that the individual listed below has elected to be exempt troom Florida Workers' Compensation law. <br /> ' Nils <br /> IIVE DATE 01129/2009 EXPIRATION DATE: 01/29/2011 <br /> PbtgFgOt FULFORD TRAVIS <br /> 1 753201272 <br /> S oSS NAME AND ADDRESS: <br /> � WATERPROOFING a cONSTRUCTION INC <br /> AO- pOTONDEILE OM STE. 410 <br /> 1 dIATIi! FL 33702 <br /> • <br /> OF BUSINESS OR TRADE: <br /> VI' dint PROOFING 2- CERTIFIED ROOFING CONTRACTOR <br /> 1�� Pettassl Is Pow 440 . 00(14), f.S.. es officer el • corperatla who elects exemption, front this chapter by 1111. • .ts a wane* of &dile Wet els <br /> x.: 11 ea recover 0•wlRs or c pasetioe a4er tills chapter. Purseael to Chapter 440.00(02). F.S., Certificates of ebetlN to N •seal... apply only MOM IN <br /> 05 baleen sr tree 11.1.1 oe the notice of election to be exempt. Fermat ie Chapter 440.06(03). F.S., NMlees el Medley to N exempt eel certified 's of <br /> s ale 11 he exempt Melt he *Niece to r•vocelia It of say time offer the lilies of the emits se the isonao• of the certificate. the penes aeon se the sales or <br /> w ind N lager meets the requirements el this adios for assumes of • certtilts h <br /> ts. The pertmest shall revoke • certificate es any Ile ler Whys el the person <br /> c •Ag 1v i r de calEkos N meet IM requirements of this section. (11 STIONS? (850) 413 <br /> _ Orman OF ELECTION TO SE EXEMPT REVISED 09 -06 <br /> ` <br />