Laserfiche WebLink
�. , <br /> ;` � <br /> 1 06 <br /> ���_.�� <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: 06/29/2011 EXPIRATION DATE: 06/28/2013 <br /> PERSON: MIRROP <br /> MARK V <br /> FEIN: 200917050 <br /> BUSINESS NAME AND ADDRESS: <br /> MIRROP CONSTRUCTION & HO�DINGS INC <br /> 31825 ROXANNE WAY <br /> DADE CITY FL 33525 <br /> SCOPES OF BUSINESS OR TRADE: <br /> 1- CERTIFIED GENERAL CONTRACTOR <br /> IMPORTANT: Pursuant [o Chapler 440 . 051141, F,S., an ofticer of a torpore[ion who elec[s exemption from this chapter 6y Filing e certificate of election under this <br /> section may not recover bene(its or compensa[ion under this chapter. Pursuant to Chepter 440.05112►, F.S., Certificetes of election [o be exempt... apply only within the <br /> scope of tbe business or [rade listed on [he notice of election to be ezempt. Pursuan[ [o Chapler 440.051131, F.S., Notices o( election to be exempt and certiFitates of <br /> election to be exempt shall be subject to revota[ion i(, at any lime after the filing af the notice or the issuance of the certificate, the <br /> certificate no longer meets the requirements of this section For issuance of a tertilicate. 7he department shall revoke a cerlificate at any time for feilure oF the <br /> nemed on the certificate to meet the requirements of this section. persan named on the notice or <br /> person <br /> JVC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01-11 QUESTIONS? (8501 413-1609 <br /> BUS�N�;SS TAX NOT`IC� • PASCU COUN'I`Y FLORID� <br /> ��� �, c.'�-2�71 1 1_. IC'.E:.NS� 1'E��'�Ft �GC:E�UIVT �L <br /> S T C Ct�T3� 15�c <br /> PAYABI.E TO: MIKE OLSON, TAX COLLECTOl� / P.O. BOX 276, DADE CITY �L 33526-0276 <br /> S I G N H E R E-� APP�CATION FOR THIS BUSINESS TAX�RECEIPT IS TRUE <br /> CORRECT <br /> �� <br /> � r ��a� GUNST�'tIJG'i":C t3hl � �-�U�_� � �� � ��: �_-- � � z 5 � � r <br /> PQ ��' �� A HORIZED SIGNATURE DATE <br /> 8f-�hl ANTCINIC! FL 33S7E,-c74L 1 <br /> ��tl:I3 bH. ic Ci�ati'_S�Ii. i <br /> �"E:M�-wt:J}i��'iY fiFCE.:I�'"i' <br /> I"f I E C �Cal�t , T X GQl..I_�l':l't3 ,- � <br /> 7 fit:T�'7' �lflL.4 i���t�?�?/:L1 ��.:fl._. "� l�ti••..__����t/M�''"' b ja��tc �� <br /> }iY --�-•--_._ _.. _. ______.___.._.. <br /> T? r`� T I' : -.- <br />