Addendum 03/04/1993
ADDENDUM TO AGREEMENT
(Public Service Building Janitorial)
~1J1\ THIS ADDENDUM TO AGREEMENT is made and entered into this
.."... . day 0 f March, 1993, between the COUNTY OF MONROE and ACE
BUILDING MAINTENANCE in order to amend that certain agreement
between the parties dated August 28, 1991, as amended on August
5, 1992, as follows:
1. The following change is to the Public Works Manual
entitled "Standard Janitorial Specifications and Requirements
Public Service Building".
"A( 1) The Contractor shall furnish janitorial services,
including all necessary supplies and equipment required in the
performance of same, for the Public Service Building Complex,
including the Public Service Building less the HRS Wing, Wing
IV of the Public Service Building, the two Gr~th M~age~nt
Trailers, and the two Public Works Trailers" ':i v.J rT1
A",_. 0
2.
This change is to the Contract Document.
s;;;
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"XIV The County shall pay to the Contr~ctor 'flor ~he
performance of said service on a per month in arrears basis o~or
before the 15th day of the following month in E:iach o~ tw~e
(12) months. The Contractor shall invoice the courytymon~ly ~r
janitorial services performed under the Specifications contained
herein. The Contract amount of this Addendum to Agreement is
$380.00 per month for a total contract amount of $2,000.00 per
month. This addendum takes effect March 4, 1993."
3. In all other respects, the agreement between the parties
dated August 28, 1991, as amended on August 5, 1992 remains in
full force and effect.
IN WITNESS WHEREOF, the parties have hereunto set their
hands and seal, the day and year first written above.
Attest:
DANNY L. KOLHAGE, CLERK
COUNTY COMMISSIONERS
COUNTY~~,
(Seal)
By: !l.1..J.. c. 1Ju~
Deputy tlerk
ACE BUILDING MAINTENANCE
Cu."c~",~ '--~!~~'-L~
'-Wi tness ........
\
(, II ,1 ! / 2 I
l/Ut~,cL) 'fi~j' IJ~{i!"-
" Witness
.
By:
Di..:;a
I, \_ ):\."-~3 l....C$
SWORN STATEMENT UNDER ORDINANCE NO. 10-1990
MONROE COUNTY, FLORIDA
ETHICS CLAUSE
~~ t3w1 ci-
warrants that he/it has not employed,
retained or otherwise had act on he/its behalf any former County officer
or employee subject to the prohibition of Section 2 of Ordinance No.
10-1990 or any County officer or employee in violation of Section 3 of
Ordinance No. 10-1990. For breach or violation of this provision the
County may, in its discretion, terminate this contract without liability
and may also, in its discretion, deduct from the contract or purchase
price, or otherwise recover, the full amount of any fee, commission,
percentage, gift, or consideration paid to the former County officer or
-,
employee.
Date:
~ 8~
(si ure)
~A~);~
STATE OF
'1-~
~A9-R _
COUNTY OF
PERSONALLY APPEARED BEFORE ME, the undersigned authority,
r C::xJbA;jc
., ()
a flxed hls(her signature
who, after first being sworn by me,
~~lU6
provided above on this
, 19 q ~
(name of individual signing) in the space
~~~
0< day of
NCTltRy PlrBLrc T...
N'1 COl>'mS~;WN :x;'t OF FlORrOA
BCNOED THRU GENERA HAR.14.J995
. . l IHS".JJIm
My commlSSlon e^pI~es:
~t~
NOTARY PUBLIC
I
~
ACE BUILDING MAINTENANCE
1200 20th TERRACE
KEY WEST, Fl33040
.
January 8, 1993
~
........--
Public Works
Jr. College Road
Key West, FL 33040
REF: Additional cleaning for Public Works
new wing
~
I am pleased to submit my bid for the
new wing cleaning as:
$380.00 per month
This cleaning is for Tuesday and Friday cleaning
of offices and halls and restrooms on other days.
of week.
Thank you for giving me this opportunity~to
submit this bid.
Sincerely,
. ._.):'-.i.~(k Z /J~
(/ . .J tJ~~
.Judy Bobick
~~..
_i'llONRO Ii:
THIS liCENSE EXPIRES
i~~.8~7UNITS: 5
.ENTER~tURRENT NU~BER CFUNITS
\.,UlJl, I Y U\.,GUI-'AIIU:,AL UlA::',::;:.:. "1''1'1 ~~-~,I:i '-j j
COUNTY-STATE OF FLOi~IDA
SEeTEi'~2t:a 30,j," 1.993
TAX
COST AND
PENALTY
; 2 2. 00
d.s YD 5 ~().
'E ~
:'CKS
'BU
STATE CERTIFICATE NUMBER
,HARRY f.:KNIGHT,C.F.C.
:lAX.COLLECTOR Z94-~403
P.O. BOXj1129 .
KEY _ WEST,- fL 330~1~1129
PLEASE SEE BACK OF FORM
:THE A80VE LICENSEE IS HEREBY
LICENSED.TO ENGAGE IN THE BUSINESS
PROFESSION CROCCUPATION OF :
J A~~ffA1ilN;~~l.R~ &i\ l{Nf.&iHU 21' . 50 CK
:)7. ~iY
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HERE:
TRANSFER FEE
TOTAL DUE
/-.
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,
ACE BUILDING.MAINTENANCE
~j.l.DY-'JUDY OWNER
P OEOX ,2763
KE.Y."l'lEST FL; 33040
02/17/93 25*OC*08*OOOOOO~009348
THIS FORM BECOMES A RECEIPT ONLY WHEN VALIDATED BY RECEIPTING
WJ\CH'NE SHOWIf~G TRANSACTION NUMBER, DATE, AND AMOUNT PAID,
ACCOUNT NUMBER IS 20566
LOCATION: HOBILE UNIT
+
THIS LICENSE MUST BE POSTED COI~SPICUOUSLY IN YOUR PLACE OF BUS~ESS
. ...
LICENSE YEAR
1992-1993
OCCUPATIONAL LICENSE
City ,of Key West, Florida
No. 50016139012.
NO REFUNDS
"1,
THIS LICENSE MUST BE PROMINENTLY DISPLAYED
LICENSE PERIOD BEGINNING 10101/92 THROUGH 09/30193
PENALTY SCHEDULE
50.00
LICENSE FEE
55.00 57.50
OCTOBER NOVEMBER
ACE 8UILDINGMAINTENANCE
'\
RECD 60111559 TR~ 0~98
ID SMA MCHD 028 LOC CKYH
CR~451 WI 02/17/93 16:31
ACCT~5001-6139-~1-2
ACE BUILDIWJ tlAINTENANCE
AMDUNT PAID: 62.5ti
156 OCC LIC 62.50
P 2 62 . 50 CH < ,{J . ~tl
FINANCE DEPARTMENT
DI VIS I Dcli3
RE
ID
CR
AC
AC
AN
15
P2
JSINESS
JDRESS:
TYPE
ICENSE:
JSINESS ~
NAME: (
TOTALiUNITS. 1~
P.O. BOX 2763
6Q RESIDENTIAL:AND/OR COMHERCIAL:CLEANING
)WNER:
DRESS:
CITY: ~
ACE BUILDING MAINTENANCE
JUDY:&8RUCE BOBICK
1200.20TH'TERRACE
KEY.WEST.FL 33040
~
~jJ
SWORN STATEMENT PURSUANT TO SECTION 287.133(3)(8),
FLORIDA STATUTES, ON PUBLIC ENTIlY CRIMES
TillS FORM MUST BE SIGNEI> AND SWORN TO IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER
OFFICIAL AUTHORIZED TO AI>MINISTER OATHS.
1.
(print name or the public entity)
for
wholle business address is
}~()O
KE'f
a..01h Tb .UACL
eVer; FtA- 06(}1~
& 5- O~~ 6f3 r;
and (If applicable) its Federal Employer Identification Number (FEIN) is
(If the entity has no FEIN, include the Social Security Number of the Individual signing this
sworn statement:
.)
2. 1 understand that a "public entity crime" as defined in Paragraph 287.133(1)(g), Florida Statutes, means a
violation of any stale or federal law by a person with respect to and dh'ectly related to the transaction of
business with any public entity or with an agenl.j' or political subdivision of any other state or of the United
States, including, but not limited to, any bid or contract fOf goods or services to be provided to any public
entity or an agent..j' or political subdivision of any other state or of the United States and involving antitrust,
fraud, theft, bribery, collusion, racketeering, conspiracy, or material misrepresentation.
3. I understand that "convicted" or "conviction" as defined in Paragraph 287.133(1)(b), Florida Statutes. means
a finding of guilt or a conviction of a public entity crime, wlih or without an adjudication of guilt, In any
fedeml or state trial court of record relating to charge~ brought by indictment or information after July 1,
1989, as a result of a jury verdict, nonjury trial, or entry of a plea of guilty or nolo contendere.
4. I understand that an "affiliate" as defined in Paragraph Z87.133(1)(a), Florida Statutes, means:
1. A predecessor or successor of a person convicted of a public entity crime; or
2. An entity under the control of any natural person who is active In the management of the entity and
who has been convicted of a public entity crime. The term "affiliate" includes those officers, directors,
executives, partners, shareholders, employees, members, and agents who are active In the management of
an affiliate. The ownership by one person of shares constituting a controUing interest In another person,
or a pooling of equipment or income among persons when not for fair market value under an arm's length
agreement, shall be a prima facie case that one person controls another person. A person who knowingly
enters into a joint venture with a person who has been convicted of a public entity crime In Florida during
the preceding 36 months shall be considered an affiliate.
5. I understand that a "person" as defined in Paragraph 287.133(t)(e), Florida Statutes, means any natural
person or entity organized under the laws of any state or of the United States with the legal power to enter
into a binding contract and which bids or applies to bid on contracts for the provision of goods or services
let by a public entity, or which otherwise transacts or applies to transact business with a public entity. The
term "person" include~ those officers, directors, executives, partners, shareholders, employees, members, and
agents who are active in management of an entity.
6. Bascd on information and bellcf, the statement which I have markcd below Is true In relation to the. entity
submitling this sworn statement. [Indlcnte which stntement npplles.]
V Neither the entity submitting this sworn statemen~, nor any of Its officers, directors, executives,
partners, shareholders, employees, members, or agents who are active In the management of the entity, nor
any affiliate of the entity has been charged with and convicted of a public entity crime subsequent to July
1, 1989. -
_ The entity submitling this sworn statement, or one or more of its officers, directors, executives,
partners, shareholders, employees, members, or agents who are active in the management of the entity, or
an affiliate of the entHy has been charged with and convicted of a public entity crime subsequent to July
1, 1989.
_ The entity submitting this sworn statement, or one or more of Its orncers, directors, executives,
partners, shareholders, employee.'!, members, or ~e.nts w"o are active in the, management of the entity, or
an affiliate of the entity has been charged with and convicted of a public entity crime subsequent to July
1, 1989. However, there has been a subsequent proceeding before a Hearing Officer or the State or Florid:!,
Division of Administrative Hearings and the Final Order entered by the Hearing Officer determined that
it was not in the public interest to place the entity submitting this sworn statement on the convicted vendor
list. [nUnch n copy or the nnnl order]
I UNDERSTAND TIIAT TilE SUBMISSION OF TillS FORM TO TilE CONTRACllNG OFFICER FOR TIlE
PUBLIC ENTllY IDENTIFIED IN rARAGRAPII 1 (ONE) ABOVE IS FOR TIIAT PUBLIC ENTllY ONLY AND,
TIIAT TillS FORM IS VALID TIIROUGII DECEMBER 31 OF TilE CALENIlAR YEAR IN WInCH IT IS FILED.
I ALSO UNDERSTAND THAT I AM REQUIRED TO INFORM THE PUBLIC ENTIlY PRIOR TO ENTERING
INTO A CONTRAl.IIN EXCESS OF TilE TIIRESIIOLl> AMOUNT PROVIDED IN SECrION 287.017, FLORIDA
STATUTES FOR CATEGORY TWO OF ANY CIIANGE IN TilE INFORMATION CONTAINED IN TillS FORM.
"
~~
· . [nature] ,
.'.,
(ef>
day or
Notary Public - State of
Sworn to and subscribed before'me this
Personally known
OR Produced identilication\):-:-JeI>
\...~~
!. . ~
,\1111"1..
,....':'..~fI,'1 Pr,i"
My comml~r"" .'<;. b"~ TIMOTHY l. TOM A
;'";fj...;-.:.i/ Novem~r 1 1 RES
"'l1ft.fI.'\\ BONDED THRU I
(Printed typed or stamped '
commissioned name ornolary public)
(Type or identilicalion)
,.
Form PUR 7068 (Rev. 06/18/92)
I . A.~..llIts
CERTIFICA TEOF' INSURANCEtjt
., '<<<"'er:"',;;: 02-18-93
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND
CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE
DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE
POLICIES BELOW.
(MM/DD/YY)
PRODUCER
The Fullers Inc
3600 Roosevelt Blvd
Key West, FL 33040
COMPANIES AFFORDING COVERAGE
Judy Bobick dba
Ace Building Maintenance
PO Box 2763
Key West, FL 33045
Bankers
INSURED
Western
f~~~~NY D
f~~~~NY E
COVERAGES;'{
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED, NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
CO
LTR
TYPE OF INSURANCE
POLICY NUMBER
POLICY EFFECTIVE POLICY EXPIRATION
DATE (MMIDDrfY) DATE (MM/DD/YY) ,
LIMITS
GENERAL LIABILITY
A X COMMERCIAL GENERAL LIABILITY
CLAIMS MADE X 'OCCUR. 93-179
OWNER'S & CONTRACTOR'S PROTo
02-18-93
02-18-94
GENERAL AGGREGATE $500,000
PRODUCTS-COM PlOP AGG. $500,000
PERSONAL & ADV. INJURY $500,000
EACH OCCURRENCE $500,000
FIRE DAMAGE (Anyone fire) $ 50,000
MED. EXPENSE (Anyone person) $ 5,000
AUTOMOBILE LIABILITY
ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
HIRED AUTOS
NON-OWNED AUTOS
GARAGE LIABILITY
EXCESS LIABILITY
UMBRELLA FORM
OTHER THAN UMBRELLA FORM
WORKER'S COMPENSATION
AND
EMPLOYERS' LIABILITY
OTHER
B Janitorial Services
Bond TBA
COMBINED SINGLE
LIMIT
$
BODILY INJURY
(Per person)
$
BODILY INJURY
(Per accident)
PROPERTY DAMAGE $
EACH OCCURRENCE $
AGGREGATE $
STATUTORY LIMITS
EACH ACCIDENT $
DISEASE-POLICY LIMIT $
--
DISEASE-EACH EMPLOYEE $
Applied For
$5,000
DESCRIPTION OF OPERA TlONS/LOCA TIONSIVEHICLES/SPECIAL ITEMS
Janitorial Services
g~~~T!!!~~g!:~5!!t~_,. ~.@~I'r:!Q!..AYsL!~$~J):
Board of Monroe County Commissioners
5100 College Rd, Stock Island
Key West, FL 33040
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO
MAIL ~ DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE
LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR
LIABILITY OF ANY KIND UPON THE COMPANY. ITS AGENTS OR REPRESENTATIVES.
'AccHifi)'2-S::SY7/90)
AUTHORIZED REPRESENTATIVE
....
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A.D..lllt,,' ..,,' CERTIFICATE. OF INSURANCE
~< '~';;.~c;;",;; ;.-i;,'{:;"~;.A/;;,;t} __'~ );:;::j;:~-Inj;.::~:1;' j'~':'Z~.J"~,-~i'r5~i_:~0ji~;;{~;'[>o_j,.c,",,:;_; \ \"}C';:,:};:":- c.;
,~,'-;;c.<_c.---c:\.c~
:\' ~ ....,;.-;,
"".--,'c.-.c.-.-.
ISSUE DATE (MMIDDIYY)
2/18/93
PRODUCER
ISLAND INSURANCE
3229 FLAGLER AVE #112
KEY WEST,FL. 33040
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS
NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND,
EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW
COMPANIES AFFORDING COVERAGE
~\U,)',.
~rv1
'!J.
+
CODE
SUB-CODE
f~~ty A BANKERS AND
INSURED
f~~~~NY B
JUDY T. BOBICK
ACE BUILDING MAINTENANCE
1200 20 TH TERR
KEY WEST,FL. 33040
COMPANY C
LETTER
COMPANY D
LETTER
COMPANY E
LETTER
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,
CO
LTR
TYPE OF INSURANCE
POLICY NUMBER
POLICY EFFECTIVE POLICY EXPIRATION
DATE (MMIDDIYY) DATE (MMIDDIYY)
ALL LIMITS IN THOUSANDS
GENERAL LIABILITY
COMMERCIAL GENERAL LJ..ABILlTY
CLAIMS MADE OCCUR.
OWNER'S & CONTRACTOR'S PROTo
GENERAL AGGREGATE
$
PRODUCTS-COM PlOPS AGGREGATE $
PERSONAL & ADVERTISING INJURY $
EACH OCCURRENCE
$
AUTOMOBILE LIABILITY
ANY AUTO
ALL OWNED AUTOS
XX SCHEDULED AUTOS
HIRED AUTOS
NON.OWNED AUTOS
GARAGE LIABILITY
FIRE DAMAGE (Anyone fire) $
MEDICAL EXPENSE (Anyone person) $
COMBINED
SINGLE
LIMIT
BODILY
INJURY
(Per p€;-son)
$ 300
$
BODILY
INJURY $
(Per accident)
6~~~~~TY $
EXCESS LIABILITY
EACH AGGREGATE
OCCURRENCE
$ $
OTHER THAN UMBRELLA FORM
WORKER'S COMPENSATION
AND
EMPLOYERS' LIABILITY
STATUTORY
$
$
$
(EACH ACCIDENT)
(DISEASE-POLICY LIMIT)
(DISEASE-EACH EMPLOYEE
OTHER
DESCRIPTION OF OPERA TIONSILOCA TIONSIVEHICLES/RESTRICTIONSISPECIAL ITEMS
1987 NISSAN STANZA
VIN:JNIHM05S1HX071568
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO
MAIL ~ DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE
LEFT, BUT FAILURE TO SUCH NOTI HALL IMPOSE NO OBLIGATION OR
LIABILITY OF ANY K D UPO PANY, IT AGENTS OR REPRESENTATIVES.
5100 COLLEGE RD
KEY WEST,FL. 33040
~ACORD CORPORATION 1988
"
ISLAND
INSURANCE
AGENCY
3229 FLAGLER AVENUE. UNIT 11,.2. KEY WEST. FLORIDA 33040 . 305-294-6666
~o;(!"..,.,
FEBRUARY 18TH, 1993
+
RISK MANAGEMENT OFFICE
BOARD OF COUNTY COMMISSIONERS
5100 COLLEGE ROAD
KEY WEST FL 33040
ATTENTION: KAY BAHLEDA
RE: JUDY T. BOBICK, D/B/A ACE BUILDING MAINTENANCE
1200 20TH TERRACE
KEY WEST, FL 33040
THE ABOVE MENTIONED INSURED IS PRESENTLY INSURED WITH
BANKERS & SHIPPERS INSURANCE COMPANY, P. O. BOX 2510,
BURLINGTON,nNORTH CAROLINA 27215.
AT THE PRESENT TIME THE BANKERS & SHIPPERS INSURANCE
COMPANY CANNOT LIST ANY GOVERNMENT ENTITY AS AN ADDITIONAL
INSURED.
THERE WILL BE A FOLLOW UP LETTER FROM BANKERS & SHIPPERS
INSURANCE COMPANY STATING THAT THEY ARE UNABLE TO LIST
THE BO~RD.OF COUNTY COMMISSIONERS AS AN ADDITIONAL INSURED.
IF THERE ARE ANY QUESTIONS PLEASE CALL OUR OFFICE.
.. .
:0.. .
C .'lSTRUCTION INDUSTRY
NOTICE OF ELECTION TO BE EXEl\fiT FROM
THE PROVISIONS OF THE FlORIDA WORKERS' COMPENSATION LAW
~i]o(q
:s0 ~\ 81~ l~~~~ TY~~ )~(~INT:
RE: . C:E ~. ; (L Pti \'J\.w f\-N ~
.l",:at D"1')n N~'r_ of Sole I'ropMon.h~ Panni&'1' or Corpcn1lon) , ~"',lf ~)
----xO -..\:l)'l( ,). ~ in ~ . .~ ~. ~ ~~
l~b.lonl f~'l west nDR, t~f\ ~3()10 (StRd~.~~ f:{lf i5q to
IC"yl (Slalr) (ZJ;>) (ndnal ~ Jbi~ HWZIbc:r1
N:l1ure Or Dusiness or Trade: ....JA. V rlV k I A L . Sf I<. VI elL-.
MAil. TO: Department of Labor & Employment Security
Dureau of W.C. Compliance .
2728 Ccnterview Drive. 100 Forrest Bldg.
Tall:ahassee. Florida 32399-0661
STATE USE ONLY
PoSTMARK DATE I
I
Thb no(lce ahllJ be In tCTcel for two (2) )'CUI from Lhc
crrC('tI"O da1e 0( until
or uDtil tc'YOl:cd. \Vb1cbcYer comes f1tiL
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As of 12;01 a.m. 30 days following the date of the mailing of this (onn, you arc hereby notified that the following Solc Proprietor.
P:lnncr ('f Corporatc Officer of the above named busIness does e1C1:tlo be excmpt from, the provisions of the Florida Wodcrs'
Compcns:lIion uw. I understand that by this action I am not entitled to benefits under chapter 440, Ronda Statutes. By filing this
(orm J hJ'.c not excccded the exemption limit of three Partners or lhree Corporate Officers. I further certify that any emplO)'ees of the
busincliS nJ.med abo,,'e are covered by workers' compensation Insurance.
The follow,';!. ~ the ccnifled or "'gislt",d license. held ~ me 9u"oanll0 ch'plcr~ ~latules (If none, so ."It):,
(I) Tl pc: u I '" ""..L . Number. .::#=S CO I 1.3 OJ It ']ypc: . Number. Q asp r
INSURANCE CARRIER INFORMATION (If Applicable): A construction Industry employer with one (1) Or more .cmployees must
maintain Workers' Compensation coverage. Fajlurc to comply will result In'a five-hundred dollar ($500) fine and on .h~mdrcd
dolJ:lr (SIOO) fine for each day of noncompliance (see section 440.43, F.S.).
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Namc,of Cmicr
C:mll:T Address
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Policy Number
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SocIal Security Number
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1}pe!Print Name '- U E.4 I C
Position: Proprietor ~rtner'--lor/Offlcer (Iitle) . : .::
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IMPORTANT: Individual exemption filing fee, pursua~t to Section 440.0.5, RS:; 'i~'~n dolJ~ and fifty cents ($':50) and is
ra).:Ible unly by money order or cashier's check, to W.C. Administrative nust Fund. AUlure to enclose fee will result in return of
reqlle\t and delay of cenification.
Insurance Agent (Agency)
Agency Address
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Signature
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