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7_G1F-U4-0523:25 POWERPNASEcIECTRIC 727�3884$21� � ��j� <br /> 07-'15-Z010 <br /> ALEX 51NK 57ATE Of FLORtDA <br /> CHIEF�iNANCIA40FFICEk DEPAiiTMENT OF FiNMIGfAL SERVICES <br /> DIVISIpN QF WORKERS' COMP�NSATION <br /> � * CERTIFIGATE 0� ELECTION TO BE EXEMPT FROM FLORIDA WpRKERS' COMPENBiATION LAW � � <br /> CONSTRUCTiON INDUSTRIP E.XEMPTlON <br /> This cer4ifies that the individu�l listed belnw has elected to he exernpt fir�m Florida Workers° Compansakian law. <br /> EFFECTIVE DATE: 07/1d/201d EXPIRATIpN DATE: 07/14/101Z <br /> PER&ON: KUBI3ZYN LEStEK <br /> FElN: 6936x�i��'I <br /> BUSINESS NAME ANG ADDI�ESS: <br /> POMER PMASE ELl�tRiC tMC <br /> 3aza cavinroN oa . <br /> fiDi,LDAM il 34891 <br /> scoPes o� aus�NESS oR T�►a�: <br /> 1- E�ECTRICALI ELBCTRICIAN <br /> IMPORT�NT v�reia�� �a CMpler ��0 Q6fi<}, f.9.. �e ei(ie�r d � c�rpar�tiu w�� elscn usepiion fr��b tYls cbP'�r by Fill�y � car111iuir ul �lecliaa r�drr tWi <br /> uctlon �n�y �o! ree�r�r M�ellu ar cn�n�eo+n��n aM�r qb e��qK I�rw�� t� G��p�er f�0.0E1121, f.3., Certlllcrt�s q Nution ro br erMpL„ �p�ly only wIMM M� <br /> scapr oi tM• bril�u+ Qr tr�N II�w an IM� �uler ol olaUea to 10 iK��M. /r�rer ro C1�pur ��o.oWt9Y, ►.s., Nuie�t �I ■I■qioe Ia Y. raM�ot MO urllNnin M <br /> ■lalio� to ba rarspf eYdi be srb�rcl ro nroc�Nsa fl �1 ry t4n �ka dio Iilip o! tMe nat{ce or tM i�r��re d fu c�rtiituu, u� p�ru� uM,1 on �e� �e6r� o� <br /> centiiui� no �pAqu ��N� ths nqulty��nlx of t11i +atlon !ar I�wuce o} � ontN�c�te, TOe kfvt�ent �M�H nroYe � :erUlitne �� py +i�� fa luWie e! ihe peeir <br /> n�eN ar t�� NWiI+Ktt� U muo INa reall�on�reis d' thiy s�oNOn <br /> aUEST10NS7 it5Ql 4t3-1f09 <br /> DWC-152 CERTIFICA'E 4F ELECTION TO BE EXEMPT REVISE� 09-06 <br /> PLEA5E CUT OU7 TME GARD iELOW ANQ RETAIN FOR �UTURE REFERENCE <br /> BTATE Oi FLORtDA <br /> D!'ARTMENT OR RINANCIAL�tRVICLi F I MPQRTANT <br /> aivuwNCFwae�es'CdMPENSATION p��su�nt to Ch�pter 4�D,051f�), F.5„ an atticer of a corpontion who <br /> CONiYRlJ�CTLON I1�ISTRY �elects exemption frern this ch�pt�r by fi inp � ClrtifiC►t� of elac�in� <br /> ClR1'1/IC/hTL ORlLlCTION TO�E�JfEMPT FROM FLORIDA �- under this section m�y nat repoW� �l��litx ar camC�ensetion under this <br /> wOltic�lS'COM�tNiAT10N LAW D chapter. <br /> EFFECTIVE 07/1S/Z010 EXPIRAIYON DJUTE: 07/14/�O1Z pyrsusnt to Ch�pHr 440.OS{121, f.S, Ceftifir,�teS ot eiectian to be <br /> PEHSOPk LESZEK K1JfISZYN H exsmpc,. �►p1y on�y within sh� scope of the busine9s w tnde liated cn <br /> FEW: i��Zfsa1 �the nptie� of yltction to be exempt <br /> BUSINESS NAME AND AD'JFiES�: E Pursusnt to C1Npter �40,45(13), F.S., !4ot�c�x pl el�Ctipn to 6a �x�mpt <br /> POWEII PMASE £LEtTXI[ IMC end cerrifiuees ef •qetiqn tp b� eRempt Sh�II bt subj�ct to nvoc�t�on <br /> 3l13 [OVIN1qN QR if, n rry rim� �ft�r tht tirinq of tAe notiee ar the issu�ce of the <br /> No�aNr, F� a•�y, c�rtilicet�, the perion rs�med on tt►e notice or eertificat� no Ipnplr meets <br /> �� rlquir�mMtS of this �ectbrs }or ieswnce ot a certNionr. TM <br /> d�p�rtm�nt ihall reroke � ce►tifieete at �ny time fDr 1Nlure of tha <br /> SCOPE dF BU51NE55 OR TFiADE: persan n�med en tht eartit;ptR to mee� the Y04�+�Om�ntS �f Mis <br /> i• ELECTIUGAL/ ELErTRKWH eaeti�n. <br /> OUESTIQNSI (i6�! d13�1$09 <br /> cur �� <br /> M Grry bottorn pvrtion on thv job, ks�p uppr�r portion fo� your raoords. <br /> owc-2s2 cEpriFfcnr� 4F EIEC?!ON TO pE EXEMPT REViSED 09-06 <br />