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SUN 2 U 1997
977AV0-j.78-495 CALLE TAMPICO — LA QUINTA, CALIFORNIA 92253 - (619)10
FAX (619) 777-7011
APPLICATION FOR
HOME OCCUPATION OF A BUSINESS
Read each condition listed .on the attachment to this form to see if the proposed activity
complies with the City's Home Occupation Regulations.
APPLICANT NAMES (List all owners, partners and/or corporation officers)
PROPERTY ADDRESS " )7 ` '�7V �tttl6�ZOO�Q PHONE a ��
BUSINESS NAME
PROPERTY OWNER
MAILINGADDRESS (if different' from business address)
TYPE OF RESIDENCE (single multiple, mobile home, etc.)
TYPE OF BUSINESS >/OQ SEK9_0 C
BRIEF DESCRIPTION OF HOW THE BUSINESS WILL OPERATE
NUMBER -OF-PERSONS INV.LVED IN.BUSINESS
LIST NAMES QF,..PERSONSS `EMPLOYED ` IVOA JE
SQUARE FOOTAGE OF USABLE FLOOR AREA IN HOUSE (exclude garage)
LOCATION, AND -SQUARE FOOTAGE OF AREA OF BUSINESS ACTIVITY IN' HOME (e�ple,
"bedroomr.= 12$ sq FW I. • 01 f�
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DESCRIPTION -O MACHt INERY :.EQUIPMENT, AND SUPPLIES BEING USED IN THE':BUSh
OPERATIONTrSx' `COwrt= '
MAILING ADDRESS - P.O. BOX 1504 - LA QUINTA, CALIFORNIA 92253
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HAVE- READ, UNDERSTAND,' AND AGREE WITH THE CONDITIONS BY WHICH A HOME
OCCU ON IS ALLOWED (conditions attached). /9-7
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Applicant's Signature Date
IF APPLICANT IS OTHER THAN PROPERTY OWNER, AUTHORIZATION OF OWNER OR
RENTAL/LEASING AGENT IS REQUIRED.
Owner/Agent Signature
Agent Company Name
Date
Date
Agent/Owner Contact Phone #
IMPORTANT: FALSE OR MISLEADING INFORMATION SHALL BE GROUNDS FOR DENYING
YOUR HOME OCCUPATION; FAILURE TO COMPLY WITH THE CONDITIONS LISTED ON THE
ATTACHED PAGE SHALL BE GROUNDS FOR REVOCATION OF PERMIT.
BUILDING & SAFETY DEPARTMENT/CODE COMPLIANCE DIVISION
DENIED SPECIAL CONDITIONS ATTACHED
I.D.#S2 DATE 6 ,90r-97
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WORKER'S COMPENSATION
ias employees, a copy of the workman's compensation policy must accompany the business
license application, indicating dates of coverage and dollar amount. This proof of coverage must be received before
the business license can be processed.
your company has employees, a copy of the workman's
If you do not have employees, please check the last line on the first page: "I certify that .....".
If your business is being operated from your home in La Quinta, a Home Occupation Permit is required before a
business license is used.
If you have any questions, please contact the Code Compliance Division at 777-705G.
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 comolete and sign a
declaration that states the following:
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury, one of the following declarations:
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.
1 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 SAID POLICY OR CERTIFICATE OF CONSENT SHOWING THE AMOUNT OF
COVERAGE AND EXPIRATION DATE FOR WORKER'S COMPENSATION IS REQUIRED TO
PROCESS THIS APPLICATION.
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 the worker's
compensation laws of California, and agree that if I hould become subject to the
worker's compensation provisions of Section 3700, 1 wi provide the Cit with a policy
or c rtific to copy within ten (10) days of the change i requirements.
Date: / Applicant:
WARNING: Failure to secure worker's compensation coverage s unlawful, and shall subject an
• employer to criminal penalties and civil fines up to $100,0 . In addition to the cost of
compensation, damages, interest, and attorney's fees may be assessed to you as provided in
Section 3706 of the Labor Code.
CONDITION OF AGREEMENT
TO HOME OCCUPATION
I understand that a Home Occupation Inspection must be done within ten (10) days from the date
of the Approved Home Occupation, June 20, 1997, for Jeffrey B. Harris, 54-385 Avenida
Alvarado. The inspection will take place when the equipment for the pool business is in storage
at the home address.
If the inspection is not made within ten days, the Home Occupation and Business License will be
suspended or revocated.
^ I QO� �✓ �/�/ Date:
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