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Aug 3011 10:09a 813-653-2023 p.5 <br /> � ,. <br /> .�• ;, <br /> � =� D1-99-20i0 <br /> � ��.- : :1 <br /> �w�_fci <br /> ALEX SIPlK STATE OF FLORIDA <br /> CHiEFFif�ANCIALCFFICEfi DEPARTMENT OF FINANCIAL SERVICES <br /> QlVIS10N OF WORKERS' COMPENSATiq� <br /> *� GERTIFlCATf OF ELECTION TO BE EXEMPT FROM FLQRIDA WQRKERS' COMPENSATI�N LAW �* <br /> CONSTRUCTION IIVDUSTRY EXEEVf�TION <br /> This certifies that the individual listed �elo�v has elected ta be exempt from florida Ulorkers' Compensation law. <br /> EFFECTlVE DATE: 01/19l2Q10 EXPIRATION DATE: 01/19/2012 <br /> PERSON: HOFFMAN GERALD <br /> FEll�i: 650949531 <br /> BUSINESS NAME AND ADQRESS: <br /> JERRY MOFFMAN COIVSTRUr'1'ION INC <br /> P 0 BOX 2164 <br /> BRANDON FL 33509 <br /> SCOPES OF BUSINESS OR TRADE: <br /> 1- CERTIFIED GENERAL CONTRACTOR <br /> It1POp7APl7: °rrsaant to CAapler A4U OSllq), F.S., a� olLcer al a corparatipn wbc elecls ezemp�ion Erom tNis chepier hy filing a certificafe ol elec�ian under :his <br /> section ma� not recover beneFits or compep;aiior u�aer Ihis chap�er_ Pursuan� lo CMapte• :t0.05(IZI, F S., Certilicnes el eleclion to Ae exempt... aFply orly wi1Li■ tne <br /> scope a` the buziness or Irace lisled on the no�ice ol =lectio� io 6e exem�t. Far3uani 10 [hapler 44).65;13F, F.S., Notices ol eleciion to 6e eKemp� end certiticate; o� <br /> eleci on lo be exemFt sball he sabjett Ic revoatiar. i(, a[ afry !ime after Ine lilfrg of the no�ice ot lEe issuaace of �he cettilieale, ihe �ersoi nan�e� an the no�ite ar <br /> certi(icaie ro langer �ceG Ih¢ req�iremems ol tkis seciioa for issuance el a certlficete. 7he �epartme�t s�all �evoke o cenific�ee .�� an�� time fot failvre af the person <br /> ramed �� IY^ certificale lo meet the requireme�ls ol [his secl:on. - <br /> IV<<C-251 CEA7IFICATE OF EtECT�OPJ 70 BE EXEMPT REVISEO 09-06 QUESTIONS? �85Q) 413-1b09 <br /> PLEASE CUT OUF TH� CARD BELOW AND RETAIN FOR �UTLAE REFERENCE <br /> STA7E OF F�ORIDA <br /> �EPARTMENT OF FINANCIAL SERV[GES lMPORTANT <br /> DNlSION �F WORKERS'COMPEHSATI�rJ _. }. �� O�ur5uan[ to ChaptCr 440_05(141, F.S., an afficar oi a corporation vrho <br /> CONSTRUCTION IAlDIlSTRY � - zfecls ezemption from this c.iapter by filin� a cartificate of election <br /> CERTIFICA7EOFELECTIONT03EEXEM.7FROWfPLDRIDA .-�``',�. L under this section may oct recov:r benefits or comp�nSation under this <br /> WORKERS' COMFENSATION LAW <br /> D chaF�er. <br /> EFFECTIVE: 01/19/201p EXPIRATION DATE: Q1/!g/2p12 <br /> PERSOV: GERALD HOFFMAN Pursuant to Chapce• 440.051121, F.S, Certifica�es ai electio� tc be <br /> H exemp:. appiy only tivilhin the scape of the business �r trede listed cn <br /> FEIN: 650149531 � the notice oi election to he exem�t. <br /> BC,511�ESS RAME AND ADORESS. R <br /> �eRAr HoFr•uw,x CONSTP.II�TION ivc E Pursuant to Chapter 440.Q�(13), F.S., T�oti�ES of electio� to b� exempt <br /> r o 3ox zisa and certificates o� election :o be exempt shzll he subj>ct to revocation <br /> 3RAtt��ON, FI 37509 �i, ot any time zfter -he ii.ing af the no:ice or the issuance oi tne <br /> certificate, the oerson named o� the noti:e o• certificate no I�nger meets <br /> the requiremenis o( this section for issuan�e oi a certiticate. 7he <br /> � deoartment shali revoke a ceni'icate at any iirne fcr failure oi the <br /> COPE �F BUSitVESS OR TRA7E: pe named or the certificate to m�et the �ea�irernents oi this <br /> � • CERTIFIED GENEA:.I CONTfi:.CTOR SBCt1011. <br /> GJESTIO�'S? ?850i 413-1609 <br /> CU7 HEFiE <br /> �� Carry bottom poriion on the job, keep upper portion for your records. <br /> VJC-252 CEfiTPICATE OF E!ECTICN TC 5E cXEA�PT R�VISEC 0E-06 <br />