Errante
• FEE $35.00
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CITY OF LA QUINTA
78-495 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 r VI CULA40
PROPERTY OWNER
PROPERTY ADDRESS
MAILING ADDRESS
SHONE ( q (,P N J
5 -PHONE q -777
TYPE OF RESIDENCE siiigT multiple, mobil home, etc
TYPE OF BUSINESS C D
DESCRIPTION OF -ROW THE BUSINESS WILL OPERATE
" EF
"Ili / ""4- - -@.eer
NUMBER OF PERSONS INVOLVED IN BUSINESS5 as
LIST NAME OF PERSONS EMPLOYED Kyo -eyjZ,
SQUARE FOOTAGE OF USABLE FLOOD
IN HOUSE (EXCLUDE GARAGE) L90
LOCATION AND SQUARE FOOTAGE OF AREA
OF BUSINESS ACTIVITY IN HOME
(EXAMPLE, "BEDROOM -125 S.F.")
DESCRIPTION OF MACHINERY, EQUIPMENT, AND SUPPLIES BEING USED IN THE
BUSINESS OPERATION
I HAVE READ, UNDERSTAND, AND AGREE WITH THE CONDITIONS BY WHICH A
HOME OCCUPATION IS ALLOWED W-CMITIONS ATTACHEDJ./ - /
A VLICANT SIGNATURE / 9ATE
IF APPLICANT IS OTHER THAN PROPERTY OWNER, AUTHORIZATION OF OWNER
OR AGENT IS REQUIRED. t
OWNER/AGENT IIGNATURE DATE
IMPORTANT: FALSE OR MISLEADING INFORMATION SHALL.-tRE GROUNDS FOR
DENYIN, . YOUR HOME OCCUPATX ? FAILURE : TO COMPLY , WI'T'H CONDITIONS
LISTED N THE ATTACHED PAGE SHALL BE"GROUNDS'.. A*.VOCATION OF
PERMIT
ui inq and Safet 'Department
/^APPROVED DENIED CONDITIONS ATTACHED
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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.
I certify that in the performance of any business activities.
for which this license is issued I shall not employ person in
P Y an Y
any manner so as to become subject to the worker's compensation
laws of California, and agree that if I should become subject to
the worker's compensation provisions of Section 3700.
Date: -Applicant:�����
WARNING: Failure to secure workman's compensation coverage is
unlawful, and shall subject an employer to criminal 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
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MAILING ADDRESS - P.O. BOX 1504 - LA QUINTA, CALIFORNIA 92253