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- __ \ . <br /> �,, �' � 03-30-2011 <br /> �•,,`°r .E.�`� . <br /> JEFF ATWATER STATE OF FLORIDA <br /> CHIEF FINANCIAL OFFICER 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: 03l30/2011 EXPIRATION DATE: 03/29/2013 <br /> PERSON: CARR DAVID <br /> FEIN: 203645197 <br /> BUSINESS NAME AND ADDRESS: <br /> CARR CONTRACTING SERVICES INC <br /> 3310 DRUM ROAD <br /> ZEPHYRHILLS FL 33541 <br /> SCOPES OF BUSINESS OR TRADE: <br /> t- CERTIFIED PLUNIBING CQHTRACTOR 2- CERTIFIED ROOFING CONTRACTOR <br /> 3- CERTIFIED GENERAL CONTRACTOR - <br /> IMPORTANT: Pursu�nt to Chapter 440 . 05114l, i.S., an officer ol e corpora[ion who elects exemption from this chapler by filiag a certificete of electian under this <br /> section may not recover benefits or campensation under this chapter Pursuanl ta Chapter 440.05112►, f.S., Certificates a( election to be exempt... apply only within the <br /> scope of the 6usiness ar traAe listed on tqe notice of election to be exempt. Parseant ta Ckapter 440.05(t31, F.S., Notices of eleclion ta be exempt and certilicales ol <br /> election to 6e exemp� shall be subject to revocatioa if, at any time after the filing of tAe no�ice or tAe issuance of �he certiticate, the person nsmed oa the notice or <br /> certificate no longer meets tbe requiremeats of this section for issusece of a certificate. The department shall revoke a certilicate at any time for failure of the person <br /> named on the certiticate to meet the requiremen�s of this sectiao. <br /> QUESTIONS? 18501 413-1fi09 <br /> DWC-252 CERTIFtCATE OF ELECTION TO BE EY.EMrT REVISED Ot-11 <br /> PLEASE CUT OUT THE CARD BELOW AND RETAIN FOR FUTURE REFERENCE <br /> STATE OF FLORIDA IMPORTANT <br /> DEPARTMENT OF RNANCIAL SERVICES <br /> DNISION OF WORKERS' COMPENSATION F Pursuant to Chapter 440.05114y, F.S., � officer of a cofporation who <br /> CONSTRIlCTION INDUSTRY � elects exemptian from this chapter by filing a certificate of election <br /> CERTIFlCATE OF ELECTION TO BE EXEMPT FROM FLORIDA �- under this Section may not recover benefits or compensation under this <br /> VYORKERS' COMPENSATION LAW D chapter. <br /> EFFECTIVE: 03/30/2011 EXPIRATION DATE: 03/28/2013 pursuant to Chapter 440.05112), F.S., Certificates of election to be <br /> PERSON: DAVID CARR H exempt.. �ply only within the scope of the business or trade listed an <br /> FEIN: 203645187 R the notice of election ta be exempt <br /> BUSINESS NAME AND ADDRESS: E Pursuant to Chapter 44Q051131, F.S., Notices of election to be exempt <br /> CARR CONTRACTING SERVICES iNC m�d certificates of election to be exempt shall be subject to revocation <br /> 3370 DRUM ROAD if, at any time after the tiling of the notice or the issuance of the <br /> ZEPHVRHILIS, FL 33541 certificate, the person named OII thB notice Of certificate f10 longer meets <br /> the requirements af this section for issuance of a certificate. The <br /> deparunent shall revoke a certificate at ar�y time for failure of the <br /> SCOPE OF BUSINESS OR TRADE: person named on U►e certificate to meet ihe requirements of this <br /> 1- CERTIFIED PLUMBING CONTRACTOR 2- CERTIFIED ROOFING CONTRACTOR section. <br /> 3- CERTIFIED GENERAL CONTRACTOR QUESTIONS? (850) 413-1609 <br /> CUT HERE <br /> * Carry bottom portion on the job, keep upper portion for your records. <br />