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Rpr 15 2011 2:19PM TEDDER-CONSTRUCTION-IhC 35Z5210096 p.2 <br /> .. __. � <br /> QI�i7�ZV1� <br /> �EFF ATWATER S'r'ATE �F FLOAIDA <br /> CMIEf FINANGUIL�ClR DIVpS10N�OF W�.7RKEFiS' <br /> +� �+ CERTIFICATE OF ELECTIpN TO BE EXEMPT FROM FLORIDA WOAK�RS' COMPENSATION LAW *�* <br /> CON$TIiUCTIQN tNOUSTRY EXEMPYION <br /> This certifiea thet the indivlduaf listed below has eiected to be exempt f�om Ftorida Workers' Compensrtian law. <br /> �FFEC711/E DATE: 03/2812011 EXPIRATION DATE: 03/Z8/�013 <br /> P�RSQN: 7EDDER JOSEPH A � <br /> FEtN: 2aza�827� �� � <br /> BtJ31NES3 NAME AND AQDRESS: � <br /> YlpOER CONSTRUCTIbMI tNC <br /> �74�Q MoORE QR <br /> pADE CITY FL 3�515 <br /> $COP�S OF BUSINHSS OR TRADE: <br /> � - co��►c'raa � <br /> IMPaI1TANT; �v�frut b CMP�a ��o • O�U41, i.s., a dllo�r �I � e�rpo�Mlln wAa �I�eH e���Ptlon Iron� �Ah cla0ki hy Illing � certlllc�h N elallos r�lq 1hu <br /> usll�n n�Y �o� neova b�Mltt� er cowpN/Mi�n wi�r 11111 el�'hr. P�r1�Mt te CM�t�� •�O.OS1121, f.8.. C�rlifi<Ilet el d�e110n to ba �M�1R01-. ■p/ly OAIy �rIU1A th� <br /> at�pe ef t6� bu�inNS er In1� itN�l e� t�� wtlo� el �I�a11o� to b� et�nyl. PrNu�m tn CYiotK 410�06117), F.l., Nalia�� 0� �I�et�w Ie e� �r�Mt �M C�hlllat�� af <br /> et�all�n to e� sre�n�t �Mdl �� �rbl�el 1� r�r�eNia lf, K��Y IfAS �1ta M� IINnp of 11� �Nie� �r tb� i��na at IAt e�rtillan�, 11u �erw� wMN e� tM Ntk� �r <br /> c�Mi{e1N �e laOK IMNS u� ��WIraA�nl� �f IAI� uttlM fv I�wua• 01 � c�rtlfltlt�• TMa bP�fl�enl ih�U ri�o�� � c�rtlUe�le tl�ny tIAN lar hllun � t1� psnoe <br /> ns�l ee Ih� o�nNleN� �a ��M 111r Itqdre�eab ol tMs �en�oM QUESTiDN57 (850) 419-160! <br /> awc CERTIFICATE OF ELECTIQN TO BE ExEMPT AEYISEO �t <br /> PLEASE CUT Ot1T TME CARD BEICW ANO RETAIN fiQR FUTURE REFERENCE <br /> 6TATi OF �LORIOA I MP�iTANT <br /> DEPAIITM�IT OF RNANCUILlERVIGei <br /> o�vliloNO�w'o11KlR!'COi1rAPCNS+►YION PursuwA te Ch�pter ,4G051t41, F.S„ an aftieer of � carpo►„�on wha <br /> CON�'iwlCTiON �NOU6TRY � eleets exsmption from �is ehapter by titinp � eenifiute of el�etien <br /> ClR1�ICATEo'ELECT10N1'06EExB�APTrROMFLQRIDA L undef this aectian rt+�y rwc recove b�nefits or compaeledvn under ehie <br /> VYORKlIW' GOhU�i�MAT10N I.AW p Ch�pte►. <br /> EFFECTIIlE: OS/ZY/7�o11 !XPlMTION OATl: �9/se/Z015 Pur�uant to Cheptar �4QQ5ft21. f.S.. C�rtl�iest�a ef elaetion to b� <br /> pEqgpN; �qSePM A TEOD�R H exemrt... ap�M oniy wiehin the scope ef ths businss� er tr.de lissed on <br /> ��� s03�Z�sTS E ehe netiee af eleetlon eo be exampti <br /> BUS�IESS NANIE AND ADDRESS: R <br /> E Purswnt to Ch�t�r ,4Q06tt81, F.S., Ne��cea of �ke�ion ee b� e�empt <br /> T�ppE� CONSTRYCTipN �MC and G�rtifiates af .feet+on ta be exempl ah.11 be S11b10Ct to reveC�tion <br /> �1�70 NOORE DR I�, at any time aite� ths tlllnp of the notiw or tl+e Itsu�nee ef the <br /> D�pe uTr, F� s9sae Ceni�icate, the p�rton Mmed on the 11otIC� or cehtfie�ee na lon0er meess <br /> tl►s r�quirementa of lhis lOCtfan lor leiu�ncs ot a certiflsne. Thb <br /> dep�rtmenl sh�ll nvoka e c�rtificete Iq �ny time tIr tsilure of the <br /> SCOPE OF BUSIN@SS OR TRADE psr:an Ilem�d on the CertifiC�te to meet the roquir�ment! ot thii <br /> 1 - CONTH4CT011 aectioa <br /> QIIESTI0NS7 1650) 413 -16D8 <br /> CUT HERE <br /> • C�rry bottom portion on th� job, k�op upp� partlon for your r�aorde. <br /> GWC-262 CERTIFlCATE OF EIECTiON TO BE ExEAAPT 11EVISEO 01-11 <br />