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A ;� <br /> . F _ = i <br /> ` <br /> i • ` 0������0�� <br /> ��_E� / <br /> JEFF ATWATER STATE OF FLORIDA <br /> CHIEFFINANCIALOFFICER 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: 02/21/2011 EXPIRATION DATE: 02/20/2013 <br /> PERSON: LASETER MICHAEL J <br /> FEIN: 371572699 <br /> BUSINESS NAME AND ADDRESS: <br /> SUN CITY CENTER PLUMBING LLC <br /> 10049 CREEK BLUFF DR <br /> RIVERVIEW FL 33578 <br /> SCOPES OF BUSINESS OR TRADE: <br /> 1- CERTIFIED PLUMBING CONTRACTOR <br /> IMPORTANT Pursuant [o CAepter 440 . 051141, F.S., an officer ol a corpontion who elects exemption From this chap[er by liling a certilicate oF election under this <br /> sec[ion may nol recover beneFits or compensa�ion under this chapter Pursuant to Chapter 440.05(121, F.S., Certiticates oF eleclion [o be exemp[... apply only within the <br /> scope oF [he business or trade lis[ed on [he notice of election to be exemp[. Pursuant [o Chapter 440.05113�, F.S., Notices of election to be exempt end cerlificates of <br /> election 10 be exempt shall be subject to revacatioa if, at any time alter the filing al the na[ice or the issuance ot the certifiate, [be person named on the notice or <br /> cerlifice[e no longer meets the requirements of this section Far issuance uF a certificate. The department shall revoke a certificate at any [ime lor tailure oF the person <br /> named on the certificate ta meet the requirements oF this section. <br /> QUESTIONS? (850) 413-1609 <br /> WC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01-11 <br /> PLEASE CUT OUT THE CARD BELOW AND RETAIN FOR FUTURE REFERENCE <br /> STATE OF FLORIDA I MPORTANT <br /> DEPARTMENT OF FINANCIAL SERVICES <br /> DIVISION OF WORKERS' COMPENSATION O Pursuant to Chapter 440.051141, 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 � L under this section may not recover benefits or compensation under this <br /> WORKERS' COMPENSATION LAW <br /> D chapter. <br /> EFFECTIVE: 02/21/2011 EXPIRATION DATE: 02/20/2013 H pursuant to Chapter 440.051121, F.S., Certificates of election to be <br /> PERSON: MICHAEL J LASETER exempt... apply anly within the scope of the business or trade listed on <br /> FEIN: 371572699 R the notice of election to be exempt. <br /> BUSINESS NAME AND ADDRESS. E Pursuant to Chapter 440.051131, F.S., Notices of election to be exempt <br /> suN CITV CENTER PLUMBING LLC and certificates of election to be exempt shall be subject to revacation � <br /> iooae CREEK BLUFF DR if, at any time after the filing of the notice or the issuance of the <br /> RIVERVIEW, FL 33578 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 af this <br /> 1- CERTIFIED PLUMBING CONTRACTOR section. <br /> QUESTIONS? (8501 413-1609 <br /> � � 3 _ (p � � I `t' � � CUT HERE <br /> Z� U <br /> �, 3_ (p1 �� 0 � Carry bottom portion on the job, keep upper portion for your records. <br /> IWC-251 CERTIFICATE OF ELECTION TO 8E EXEMPT REVISED 01-11 <br />