Head & HawkinsrFEE
$35.00
CITY OF LA QUINTA
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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
PROPERTY OWNER PHONE j/
PROPERTY
PROPERTY ADDRESS -
MAILING ADDRESS
TYPE OF RESIDENCE sin le ultiple, mobil home, etc.)
TYPE OF BUSINESS
BRIEF DESCRIPTION OF HOW THE BUSINESS WILL OPERATE ,
/1//�z`"
NUMBER OF PERSONS INVOLVED IN BUSINESS
LIST NAME OF PERSONS EMPLOYED r
• SQUARE FOOTAGE OF USABLE FLOOR AREA
IN HOUSE (EXCLUDE GARAGE)
LOCATION AND SQUARE FOOTAGE OF AREA
OF BUSINESS ACTIVITY IN HOME GpJ � op L�
(EXAMPLE, "BEDROOM -125 S.F.") U
DESCRIPTION OF MACHINERY, EQUIPMENT, AND SUPPLIES BEING USED IN THE
BUSINESS OPERATION ��-r>LS L-zx�V-
I HAVE READ, UNDERSTAND, AND AGREE WITH THE CONDITIONS BY WHICH A
HOME OCCJJPATION IS A:.LOWEfi (COPDITIONS ATTACHED), _ _
SIGNATURE" ' DATE
IF APPLICANT IS OTHERPROPERTY OWNER, AUTHORIZATION OF OWNER
OR AGENT S REQUIRED.
7 A
0 R/A ENT S I)WWTURE DATE
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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.
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Buildi and Safety Department
P_ROVED DENIED CONDITIONS ATTACHED COVsP
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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 any person in
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 q
ion 3700.
Date: - Applicant: 'M"J, , /, ) _kj�
cc W AJ
WARNING: Failure to secure workman's compe ation 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
MAILING ADDRESS - P.O. BOX 1504 - LA CQUINTA, CALIFORNIA 92253
0
STATE P.O. BOX 420807, SAN FRANCISCO, CA 94142-0807
COMPENSATION
I NSUFt AN C:r= ti
FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
v
'c POLICY WIVIBER'-'�'2 2 9 --Sl 4 UNIT 00088"
NOVEMBER 7, 19 Dhd
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CERTIFICATE EXPIRES.
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PGA WIEST H.O.A.
ATT11 RACHELLE THOMPSON
P.O. BOX 1060
LA QUINTA CA 92253
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This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the California A
Insurance Commissioner to the employer named below for the policy period indicated.
This policy is not subject to cancellation by the Fund except upon ten days' advance written notice to the employer.
We will also give you TEN days' advance notice should this policy be cancelled prior to its normal expiration.
This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded 'by the -a''
policies listed herein. Notwithstanding any requirement, term, or condition of any contract or other document with .0"
respect to which this certificate of insurance may be issued or may pertain, the insurance, afforded by the policies
described herein is subject to all the terms, -Iexclusions 'and 66nditions of such ,'policies. —
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YS ,N PRESIDENT
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EMPLOYER
TERRY W. SMITH AND CRAIG-Pt'TERSEN
INTEGRITY CONSTRUCTION
77455 DELAWARE PLACE
PALL DES ERT CA 92260 CA 7..
4k
SCIF 10262
POLICY HOLDER'S COPY
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"A.
EMPLOYER
TERRY W. SMITH AND CRAIG-Pt'TERSEN
INTEGRITY CONSTRUCTION
77455 DELAWARE PLACE
PALL DES ERT CA 92260 CA 7..
4k
SCIF 10262
POLICY HOLDER'S COPY