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CourtneyFee $35.00 78-495 CALLE TAMPICO = LA QUINTA, CALIFORNIA 92253 - (619) FAX (61 APPLICATION FOR HOME OCCUPATION OF A BUSINESS . 777-7050 777-701.1 3_11t*_ _ ;3d1G 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) C6 «) PROPERTY ADDRESS S�Z-/7b PHONE -776--z-S0`( BUSINESS NAME AFFOZ�K�x� ti/CL 04AILING ADDRESS (If different from business address) TYPE OF RESIDEN(Z!!(single,)iultiple, mobile home, etc.). TYPE OF BUSINESS d— L6VDSCAj1y^3 0� BRIEF DESCRIPTION OF HOW THE BUSINESS WILL OPERATE NUMBER OF -P RSONS INVOLVED IN..BUSINESS Z LIST NAMES -OF PERSMS EMPLOYE -12A 42by�v�� /�c�c��T•tJ '.IC..' "fir, . r, . ,_ . ........ ..:.. • •.°,; ..... '� �,t. l %;;,' ABLE FLOOR AREA N SQUARE FOQTAGEMHOUSE (exclude g rage) LOCATION AND SQUA'I`3E F©MAGE. OF AREA OF BUSINESS`:ACTIVT� r --JN HOM��-�ekample; = „bedroom 125 sq. Ft• ,,..r�D M t -, .) ` lOf3 G FrCONS:': . . ..... :.; .: OESCRIPtION''OFMIACAINERY, EQUIPMENT, AND SUPPLIES BEING USED.•1N 'T. H. -BUSINESS OPERATION MAILING ADDRESS P.O. BOX 1504 - LA QUINTA, CALIFORNIA 92253 1111111 r� 4 78-495 CALLE TAMPICO — LA QUINTA, CALIFORNIA 92253 - (619) 777-7050 FAX (619) 777-7011 APPLICATION FOR 1/� r] Fee $35-00 HOME OCCUPATION OF A BUSINESSI� it NIAY 2 ' �1,96 V i Read each condition listed on the attachment to this form to see if tiYe-proposed-activity complies with'the City's Home Occupation Regulations. APPLICANT N-AMES (List all owners, partners and/or corporation officers) ZPuiA)QO PROPERTY ADDRESS 5�1-17e!) e9yc`yip4 PHONE -7-76-zS9;1 BUSINESS NAME PROPERTY OWNER 'r �( T)oNNW GorJZZ2vb�l MAILING ADDRESS (if different from business address) TYPE OF RESIDEN (single, ultiple, mobile home, etc.) TYPE OF BUSINESS d- Lf1iVL)-1:k--Af1;N3 5 BRIEF DESCRIPTION OF HOW THE BUSINESS WILL OPERATE NUMBER OF PERSONS INVOLVED IN BUSINESS Z LIST NAMES OF PERSONS EMPLOYED efa2eZ9ZE- % SQUARE FOOTAGE OF USABLE FLOOR AREA IN HOUSE (exclude garage) LOCATION AND SQUARE FOQTTAGE OF AREA OF BUSINESS ACTIVITY IN HOME (example, "bedroom - 125 sq. Ft.) oP • DESCRIPTION OF MACHINERY, EQUIPMENT, AND SUPPLIES BEING USED IN THE BUSINESS OPERATION /nista A I MAILING ADDRESS - P.O. BOX 1504 - LA QUINTA, CALIFORNIA 92253 ��( 9� r I HAVE READ, UNDERSTAND, AND AGREE WITH THE CONDITIONS BY WHICH A HOME OCCU OW (con ' 'ons attached). • Date 5._0-9_ 96 Ap s Signature • IF APPLICANT IS OTHER THAN PROPERTY OWNER, AUTHORIZATION OF OWNER OR RENTAL/LEASING AGENT IS REQUIRED. Date Owner/Agent Signature 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 APPROVED DENIED SPECIAL CONDITIONS ATTACHED BY:AA� I.D.#✓� countera F l T ry - Ativ,,, 4 �Q�rw 78-495 CALLE TAMPICO — LA QUINTA, CALIFORNIA 92253 - (619) 777-7000 FAX (619) 7774101 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 or 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.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 MAILING AODRESS - P.O. 80X 1504 - LA QUINTA, CALIFORNIA 92253