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• FEE $35.00 Vx
CITY OF LA QUINTA jj78-495 Calle Tampico, P. O.Box 1504, La Quinta, CA 92253
HOME OCCUPATION PERMIT
Read each condition listed on the attachment to this form to see if
the proposed activity can comply with the City's Home Occupation
Regulations.
BUSINESS NAME /- C Tv PHONE Aor
PROPERTY OWNER S PHON—
PROPERTY ADDRESS S t/l'UG� o - L l v
MAILING ADDRESS
TYPE OF RESIDENCE singl multiple, mobil home, etc.)
TYPE OF BUSINESS
BRIEF DESCRIPTION• OF OW THE BUSINESS WILL OPERATE
NUMBER OF PERSONS TWUOLVED IN BUSINESS
LIST NAME OF PERSONS EMPLOYED
• SQUARE FOOTAGE OF USABLE F OOR AREA
IN HOUSE (EXCLUDE GARAGE
LOCATION AND SQUARE FOOTAGE OF AREA
OF BUSINESS ACTIVITY IN HOME
(EXAMPLE, "BEDROOM-125 SS..FF.")
DESCRIPTION F MACHINyRY, EQUIPMEIdT,'AND SUPPLIES BEING USED IN THE
BUSINESS OP RATION Jec�(
I HAVE READ UNDERSTAND, D AGREE WITH THE CONDITIONS BY WHICH A
HOME OCCUPA ON IS ALLOWE (CONDITIONS ATTACHED).
A A,
APP C SIdNATUaE DATE _._.
IF. APPLI'CAU4 13 0' F TIV5N P; e(y s ERTY OW -, ?#lYTiNORIZATION OF OWNE£,-
OR-.AGENT IS REQUIRED.
QMER/AGENT SIG?sir ` �w DATE
IMPORTANT: FALL; OR MISLK--� )ING TVIFORMA ON SHAI. flrE1E GROUNDS FOR
DENYING YOUR kO'e�E OCCUPA ON; FAILURE G- COMPLY CONDITIONS
LISTED ON �-T= ATTACHED PA GE SY-ALL BE G.AOU"S F'bir, 1".4-N ATION 0
PERMIT.
ildi ana�� Safety Del2artment
APPROVED � D����TED CC','!2 T10jAS ATTACHED
4 4aQumrw
78-495 CALLE TAMPICO — LA QUINTA, CALIFORNIA 92253 - (619) 777-7000
FAX (619) 777-7101
Every employer who applies for any license or a renewal of any
license for a business issued pursuant to Section 37101 of the
Government Code or Section 7284 of the Revenue and Taxation Code
shall complete and sign -a declaration that states the following:
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury, one of the following
declaration:
I have and will maintain a certificate of consent to self -
insure for worker's compensation, as provided by Section 3700 for
the duration of any business activities conducted..for..which this
license is issued.
I have and will maintain worker's compensation insurance, as
required by Section 3700 for the duration of any business
.
activities conducted for which this license is issued.
My worker's compensation insurance carrier and policy number:
Carrier:
Policy Number:
A "COPY" OF THE POLICY SHOWING THE AMOUNT OF COVERAGE AND
EXPIRATION DATE _FOR WORKMEN'S COMPENSATION IS REQUIRED -TO PROCESS
THIS, —APPLICATION.
.L—/— I certify that in the performance of any business activities
for which this license is issued I shall not employ any person in
any manner so as to become subject to th, worker's compensation
laws of California, and agree that if I sh uld become subject to
the worker's c provisions of Section 3700.
(m�pensation
Date: �� I Applicant:
WARNING: Failure to secure workman's pensation coverage is
unlawful, and shall subject an employer t riminal penalties and
civic fines up to $100,000. In addition to the cost of
compensation, damages as provided for in Section 3706 of the Labor
Code, interest, and attorney's fees.
bus.fac
MAILING ADDRESS - P.O. BOX 1504 - LA OUINTA, CALIFORNIA 92253®�.