STONE0
bOX
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La Quintinta, CA 92253
01 CITY OF LA QUINTA -2246
(619) 564
HOME OCCUPATION APPLICATION
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.
APPLICANT'S NAME �l lbs �� 7��� PHONE
PROPERTY OWNER PHONE Ste,
PROPERTY ADDRESS
TYPE OF RESIDENCE Csiriglqe multiple, mobile home, etc.).�fcw/i
_ r
TYPE OF BUSINESS L�
o e/
BRIEF DESCRIPTION OF HOW THE BUSINESS.WILL OPERA;'E 4"4(wLfcLCr L�md�rP.
P,r. fr- F 4A(!7. l/Jfe0,P V,,:5 etvl w(DWAO S _
NUMBER OF PERSONS INVOLVED IN BUSINESS J9(4:�
LIST NAMES OF PERSONS EMPLOYED MVs
SQUARE FOOTAGE OF USABLE FLOOR AREA IN
HOUSE (EXCLUDE GARAGE) 2100 15q V�_ UqqjANWASTAMP.
LOCATION AND SQUARE FOOTAGE OF AREA OF APR 2 81993
BUSINESS ACTIVITY IN HOME (EXAMPLE,
"BEDROOM - 125 S.F.") ��® ffz'
DESCRIPTION OF MACHINERY, EQUIPMENT, ANP
SU301
Iff SU IN
BUSINESS OPERATION 419Fr1oV. 6(.-S 6W t _rO066 Of
h HAVE READ, UNDERSTAND, AND -AGREE WITH THE CONDITIONS BY WHICH A HOME
OCCUPATION IS ALLOWED (CONDITIONS ATTACHED).
Vy`"aV,J—DL_� I
APPLICANT SIGNA
/ter/g f>
DATE
IF APPLICANT IS OTHER THAN PROPERTY OWNER, AUTHORIZATION OF OWNER OR AGENT
REQUIRED.
OWNER/AGENT SIGNATURE DATE
IMPORTANT: False or misleading information shall be grounds for denying
your Home Occupation; failure to comply with conditions listed on the
attached page shall be grounds for revocation of permit.
Build' and Safety D a tment L
APPROVED S DATE �/ � CONDITIONS ATTACHED
DENIED BY DATE
1993 BUSINESS LICENSE APPLICATION FORM
BUS. LIC. NO.
A. !Estimated Gross Business
Receipts for New Businesses Only:
v $ V V V
00
B. Previous Year Gross Receipts For Established Businesses:
********GOOD ONLY FOR JANUARY 1,1993 THRU DECEMBER 31,1993*******
I HEREBY CERTIFY that all the information supplied by me is correct and
any licenses required by the County, State or Federal Government have been
issued to me and are ,a-4ull force and effect.
Signature Title D
iSubmit Form To:
CITY OF LA QUINTA
BUSINESS LICENSE DIVISION
P.O. Box 1504
La Quinta, CA 92253
......PROOF OF WORKERS COMPENSATION INSURANCE IS REQUIRED........
APPROVED BY BUILDING & SAFETY DEPARTMENT
/
1.
IS THIS BUSINESS LOCATED AT YOUR HOME:
YES (/ NO
2.
Business Name: tLE00_ 1_--
3.
Business Address: 4.
Mailing Address:
5.
Business Phone:
6.
Owned By: CORPORATION PARTNERSHIP INDIVIDUAL
7.
If Corporation or Partnership: Tax I.D.#
8.
If Individual Owner: Social Security #
`7-
9.
Name of Owner �,L/Ot�ll�5 �, , STOJ F;
Title:
•
Or Officers
10.
Type of Business: ��P '*j L� Gt
11.
SBE Resale Number:
12.'-
BUSINESS LOCATED WITHIN THE CITY .OF LA
QUINTA (Does Not Apply To
Building Contractors):
A. !Estimated Gross Business
Receipts for New Businesses Only:
v $ V V V
00
B. Previous Year Gross Receipts For Established Businesses:
********GOOD ONLY FOR JANUARY 1,1993 THRU DECEMBER 31,1993*******
I HEREBY CERTIFY that all the information supplied by me is correct and
any licenses required by the County, State or Federal Government have been
issued to me and are ,a-4ull force and effect.
Signature Title D
iSubmit Form To:
CITY OF LA QUINTA
BUSINESS LICENSE DIVISION
P.O. Box 1504
La Quinta, CA 92253
•
78-105 CALLE ESTADO — LA QUINTA, CALIFORNIA 92253 - (619) 564-2246
FAX (619) 564-5617
Dear Business License Applicant:
Every employer who applies for any license or for 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 the states the following:
WORKERS' COMPENSATION DECLARATION
I hereby affirm, under penalty of perjury, one of the following
declaration:
L/
I have and will maintain a certificate of consent to self -
insure for workers' 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 workers' compensation insurance carrier and policy number
are:
Carrier
Policy Number
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 workers'
compensation laws of California, and agree that if I should
become subject to the workers' compensation provisions of
Section 3700 of the Labor Code, I shall forthwith comply with
the provisions of Section 3700.
Date: 2 Applicant
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS
UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND
CIVIL 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.
MAILING ADDRESS . P.O. BOX 1504 • LA QUINTA, CALIFORNIA 92253