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� � <br /> � .r - <br /> 03-10-2011 <br /> . � ����,�"� <br /> _ �- <br /> JEFF ATWATER STATE OF FLORIDA <br /> cHi��wwcuu.�c�e DEPARTMENT OF FINANCIAL SERVICES <br /> DiViS10N OF WORKERS' COMPENSATION <br /> ** CERTIFICATE OF ELECTI�N TO BE EXEMPT FRDM FLORIDA WORKERS' C�MPENSATION LAW *� <br /> CONSTRUCTION INDUSTRY EXEMPTION <br /> This certifies that the individual listed below has elected to be exempt from Fio�ida Woricers' Compensation law. <br /> EFFECTIVE DATE: 03/10/2011 EXPIRATION DATE: 03/09/2013 <br /> PERSON: RlTCHIE TODD <br /> FEIN: 364529874 <br /> BUSINESS NAME �1ND ADDRESS: <br /> TODD'S CONTRACTIN6 CORP <br /> 774 WAI �ANI ROAD <br /> PALM HARBOR FL 34683 <br /> SCOPES OF BUSINESS OR TRADE: <br /> 1- GENERAL CONTRACTOR <br /> IMPORTANT: P�rsaant to CMap[er 440 . 05(141, f.S., sn officer of a coryontioa wpo elects exemptioa (ron tMis c�apter by filieQ s certific�te ot electioa un�er tYis <br /> sectio� way sot recover beee(ia or co�apansatioa aaAer tUis cMapter. Psrwxt to CMap�er 440.05112►, F.S., CertiHc�tes of efectioa ta be exempt.., appty o�ly withi� [he <br /> scepe of tke brsiness or In�e listed on the notice oF election to ba eaewpt. Pe�sdant tu CMapter 440.05(t3►, F.S., Notices of election to 6e exempt and c�rtificnes of <br /> election to be exempt skall be sa6ject to revocatioa if, a[ any time af[er the filiqg of the notice or the issaance of tMe certiticate, tpe persoa eamed on the no[ice or <br /> certificate no lonqer meets the requirements of tbis section for issnance ot a certi(icste. TAe department shall revoke a certiflca[e at any tlme for lailure ol the person <br /> named on tbe ttrtilicate ta meet tde requiremeets ot tAis sectioa. <br /> QUESTIONS? (850) 413-1609 <br /> DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01-11 <br /> PLEASE CUT OUT THE CARD BE101N AND RETAIN FOR FUTURE REFERENCE w <br /> STA� � �.owan IMPORTANT <br /> oWnRrM�r oF � sexwces <br /> DMSION OFYYORKER� 00�9�IS�ATIOId O Pursuent to Cpapter 440.05114), F_S, an officer of a corporotion who <br /> COI�ISTRIII.?ION II�OUSTRr elects exemption from this chapter by fiiirg a certificate of election <br /> c�cA7E oF a.EC7�oN 7o ee oce�t�'r � F1owDn l under this seccion <br /> w�K�ts �5�►noN uw may not �ecover benefits or compensation under ffiis <br /> D chapter_ <br /> EFFECTIVE: OCi/10/2011 EXPIRATION DATE: 03/09/2013 H p��SUaM to (�pter 44Q05(121, F_S_, Certificates of election to be <br /> PERSONt TODD RITCHIE exempt_ apply only witttin the scope of tl�e business or vade fisted on <br /> FEII1t 384529874 R the notice of election to be exempt <br /> BUSINESS NAME AND ADDRESS: E Pursuant to Cf�apter 440.05113}, F.S, Notices of election to be exempt <br /> TODD'S CONTRACTWG CORP <br /> ��a wni LANI ROAD and certificates of election to be exempt sf�ell be subject to revocation <br /> if, at ary time after the filing of tf�e notice or the issuaice of the <br /> VALM HARBOR, FL 346B3 eertificate, the person named on the notice or certificate no longer meets <br /> the requirements of this sectioo for issus�ce of a certificaRe. The <br /> depariment shall revoke a certificate at ary time far failure of the <br /> SCOPE OF BUSINESS OR TRADE person named a� U�e certificate to meet U�e requiremerrts of this <br /> i - c�wu coNrnacroR sectio�. <br /> QUESTIONS? (850) 413-1609 <br /> CUT HERE <br /> +► Carry bottom portion on the job, keep upper portion for your records. <br /> DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REYISED 01-11 <br />