Opening of Qualifications - RFQ - Qualified Contractors for Lead Hazard Reduction Demonstration Grant - Building Millenium Consultant Construction LLC

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SSTEVEN MARTIN 1502 NORTH OLNEY ST INDIANAPOLIS, IN 46201 State Form 56478 (1-18) Workers Compensation Board of Indiana 4- � 01. Clearance Certificate for Independent Contractors SEAL' Name of Independent Contractor Trade Name of Independent Contractor Specified Trade SSTEVEN MARTIN MM HOMES RESTORATION CONSTRUCTION Address FEIN or SSN Phone 1502 NORTH OLNEY ST xxx-xx-9647 (317) 640-2508 INDIANAPOLIS, IN 46201 E-mail Address Date Issued: Affidavit of Exemption Number MM HOMES RESTORATION 3/25/2019 149504 Is applicant an Indiana resident? YES If not, state of residence: Pursuant provisions of IC 22-3-2-14.5 and/or IC 22-3-7-34.5, Applicant has confirmed the following information in pursuit of the issuance of this Independent Contractor Certificate of Exemption: YES Applicant is an independant contractor, as defined by IC 22-3-6-1(b)(7) and/or IC 22-3-7-9(b)(5). NO Applicant is a sole proprietor as defined by IC 22-3-6-1(b)(4) and IC 22-3-7-9(b)(2) Sole Proprietorship name: Business ID: NO Applicant is in a partnership as defined by IC 22-3-6-1(b)(5) and IC 22-3-7-9(b)(3) Partnership name: Business ID: NO Applicant's independendant contractor business is an LLC, an S corporation, or otherwise incorporated and applicant is an officer of that corporation. NO Applicant has employees, Pursuant to the authority vested in me and in reliance upon the express representations made above, I hereby certify that applicant is entitled to and hereby is declared to be exempted from purchasing worker's compensation insurance coverage for the applicant identified above. Worker's Compensation Board VALID Mary Taivalkoski 3/25/2019 Executive Administrator This certificate expires one (1) year from validation date. State Use Only $ 20.00 Filing Fee Paid DOR Filing Fee $5.00 WCB Filing Fee $15.00 Date Entered: 3/25/2019 Validation Date: 3/25/2019