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��-��a <br /> � �� . <br /> ' = \ <br /> < <br /> , ! - �� 06-22-2011 <br /> ��. sd <br /> 1�uu�E�f" <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: 06/22/2011 EXPIRATION DATE: 06/21/2013 <br /> PERSON: ALVAREZ TIMOTHY A <br /> FEIN: 260419912 <br /> BUSINESS NAME AND ADDRESS: <br /> ALUMINUM CONCEPTS OF FLORIDA LLC � <br /> 3733 LADO DR <br /> WESLEY CHAPEL FL 33543 <br /> SCOPES OF BUSINESS OR TRADE: <br /> 1- CERTIFIED SPECIALTY CONTRACTOR 2- SCREENING <br /> 3- FENCE ERECTION 4- CONCRETE WORK <br /> IMPORTANT Pursuant to Chapter 440 051141, F.S., an officer aF a corporation who elects exemption From this chapter by Filing a certificate of election under this <br /> section may not recaver beneFits or compensation under [his chapter Pursuant to Chap[er 440.051121, F.S., CertiFicates af election to be exempt... apply only within the <br /> scope ol the business or trade listed on [he notice of election to be exempt. Pursuant to Chapter 440.051131, F.S., Notices of election to be exempt and certifica[es of <br /> electian to he exempt shall 6e subjec[ to revocation if, at any time af[er the filing of the notice or the issuance af the certificate, the person named on the natice or <br /> certifica[e no langer meets the requirements oF [his sec[ion far issuance oF a certifica[e. The department shall revoke a certiFicate at any time for Failure of the person <br /> named on the certifica[e to mee[ the requirements of this sec[ion. <br /> QUESTIONS? (850) 413-160 <br /> DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01-11 <br /> PLEASE CUT OUT THE CARD BELOW AND RETAIN FOR FUTURE REFERENCE <br /> STATE OF FLORIDA IMPORTANT <br /> DEPARTMENT OF FINANCIAL SERVICES <br /> DIVISION OF WORKERS'COMPENSATION O Pursuant to Chapter 440.05(14�, F.S., an offi�er of a corporation who <br /> CONSTRUCTION INDUSTRY elects exemption from this chapter by filing a certificate of election <br /> CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA .a L under this sectian may not recover benefits or compensatian under this <br /> WORKERS'COMPENSATION LAW `°^-^^"� D chapter. <br /> EFFECTIVE: 06/22/2011 EXPIRATION DATE: 06/21/2013 H pursuant to Chapter 440.05(121, F.S., Certificates of election to be <br /> PERSON: TIMOTHY A ALVAREZ exempt... apply only within the scope of the business or trade listed on <br /> FEIN: 260419912 R the notice of election to be exempt. <br /> BUSINESS NAME AND ADDRESS: E Pursuant to Chapter 440.05(13), F.S., Notices of election to be exempt <br /> ALUMINUM CONCEPTS oF FLORIDA uc and certificates of electian to be exempt shall be subject to revocation <br /> 3733 LADO OR if, at any time after the filing of the notice or the issuance of the <br /> WESLEV CHAPEL, FL 33543 certificate, the person named Ofl th8 notice Of certificate I10 longer meets <br /> the requirements of this section for issuance of a certificate. The <br /> department shall revoke a certificate at any time for failure of the <br /> SCOPE OF BUSINESS OR TRADE: persan named on the certificate to meet the requirements of this <br /> 1- CERTIFIED SPECIALTY CONTRACTOR 2- SCREENING SBCYIOfI. <br /> 3- FENCE ERECTION 4- CONCRETE WORK 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 REVISED 01-11 <br />