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.��• <br /> OS-11-2009 <br /> ALEX SINK STATE OF FLORIDA <br /> �� Fl�� � DEPARTMENT OF FINANCIAL SERVICES <br /> DIVISION OF WORKERS' COMPENSATION <br /> �� CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORI(ERS' CpMpENSATION LAW ** <br /> CONSTRUCTION I(�USTRY EXEMPTION <br /> This certifies that the individual listed below has elected to be exempt from Florida Workers' Compensation law. <br /> EFFECTIVE DATE: 06/17/2009 EXPIRATION DATE: 06h7/2011 <br /> PERSON: MARSHALL EVA 11A <br /> FEIN: 204567523 <br /> BUSINESS NAME AND ADDRESS: <br /> TKJ CpNSTRIJCTION I�M�AN1( INC <br /> 37806 MARCLIFF TERRACE <br /> ZEPHYRHILLS FL 33541 <br /> SCOPES OF BUSII�SS OR TRADE: <br /> 1- CERTIFIED ROOFING CONTR/►CTpR <br /> IMPORTANT: Pns�a�t to CY�pter 440 . 05(iM, i.S., ae sfficer o! a c�rMratie� rr�a elec[s exaw/tia frs� tYis cYyter 9y fili�g a certiticrte ot elec[ioo �Ner tYis <br /> sectiee �ay �et rocorer bnMits sr ceysuuiw p�er tlis cMqler. P�swt to CMpter 4I0.051121, F.S_, Cati(icates of electix p be exe�.. sppiy o�ly wit►i� tqe <br /> scope o( tbe Msi�eu or trale Iistel �o tYe wtice ol electie� te be exept_ P�rs�t to Crapter 410.05{131, F.S., N�tices af eleUiw m be exept a�� certilicries a( <br /> electio� to be ezew't sMall be s�bjep to revoutie� i(, �t wy �i�e aher qie Filiy af Ne wtice or tAe iss�ace ot Ire certificqe, tYe perwn u�e� oa t�e �otice or <br /> certificste �o Iw�er eeets Ne reqire�e�ts �f tiis sectio� for iszwce d a certificate. Ttie Ieput�eM sYa11 rc�ete a certificate at ary ti�e for Failrre of Ne perma <br /> aamed oe tMe certi(icrie to �eet tre req�irwens of tAis seuiop. <br /> OWC-251 CEZTIFICA7E OF ELECTION TO BE EXEMPT REVISED 09-06 QUESTIONS? (850) 413 <br /> . <br /> Q5-11-2009 <br /> ALEX SINK STATE OF FL4RIDA <br /> CHIEF FlNANCU4L OFFICER DEPARTMENT OF FINANCIAL SERVICES <br /> DIVISION OF WORKERS' COMPENSATtON <br /> *� CERTIFICATE OF ELECTi�II TO BE EXEMPT FR�111 FLORIDA WORKERS' COMPENSATION LAW ** <br /> CQNSTRUCTION II�USTRY EXEMPTION <br /> This certifies that the individual listed below has elected to be exempt from Florida Workers' Compensation law. <br /> EFFECTIVE DATE: 06/17/2009 EXPIRATION ATE: 06/17/2011 _/�� <br /> �-- — - --- <br /> PERSON: ppyy�ER LAVERNE C <br /> FEIN: 204567523 <br /> BUSINESS NAME AND ADDRESS: <br /> TKJ CONSTRUCTION l�ANY INC <br /> 37606 MARCIIFF TERRACE <br /> ZEPHYRHILLS FL 33541 <br /> SCOPES OF BUSINESS OR TRADE: <br /> 1- CERTIFIED ROOFING CON1'RACTOR <br /> IMPOpTANT: Prrsrsnt to C4spler 440 . O6(14), F.S., sa o((icer of e coryantioa wbo slecls ex�nption (roa tlis cM�pter by fili�g a certificate oF electioe re/er tbis <br /> seqion aay not recorer beaefits or cospeasNiop wder tAis cAapter. P�nr�ot to CYapter 440.05(121, f.S., Cartiflc�tes of elecli�a to be exewpt... apply osly NifMlp t!e <br /> scope of tAe busiasu or VaAe li�ed oo t!e no[ice of electios to be exewot. Pors���t tu LY�pter 440.051131, F.S., NWices of slectio� te be exeApt �M cettificales e( <br /> electioe to 6e exe�pt sYNI De srbject ro roracetina i(, �t s�y ti�e Mter tYe ftliay of tie �atice m tYe issrt�ce oi t!e certificale, tpt person ntned os tYe potice or <br /> certificate wo losger seets [ha raqrire�neets of tpis section lor isssaece o( a certificate. TYe /ep�rt�e�t sYall revoke � certific�te �t a�y time for fail�re of the persoa <br /> ■ased oa tbe certificste [o meet tAe reqdre�oeats of tAis seetion. - <br /> DWC-�52 CERTIFICATE OF ELECTION TO BE EXEMPT REVISEO 09-06 aUESTIONS? (850) 413-1609 <br />