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FPC FAX SYSTErl PHONE N0. I (VIII VIII IIII IIII Mar. 17 1997 09:08AM P1
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78-42S CALLE TAMPICO — LA QUINTA, CALIFORNIA 92253 - (619) 777-7050
FAX (60) 777-7011
APPLICA'T'ION FOR
Fee $35.00 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 owneKs, partners and/or corporation officers)
PROPERTY ADDRESS l��%�� �� PHONE
BUSINESS NAME
�ROPERTY OWNEI
MAILING ADDRESS tit different from business address)
TYPE OF RESIDEN {singl , multiple, mobile home, etc.)
TYPE OF BUSINESS lo` /0��� -
BRIEF DESCRIPTION OF HOW THE BUSINESS WILL OPERATE
DUMBER OF PERSONS INVOLVED IN BUSINESS
LIST NAMES OF PERSONS EMPLOYED
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SQUARE FOOTAGE OF USABLE FLOOR AREA IN HOUSE lexclude garage) jza*
r^,. LOCATIO"D SQUARE FOOT GE.OF AREA OF BUSINESS ACTIVITY IN HOME (example,
'bedroom - 125 sq. Ft.) '
-DESCRIPTION OF MACHINER Q IPMENT, AND SUPPLIES BEING USED IN THE BUSINESS
OPUtATION A4_42L x,1.4/;
MAILING ADDRESS - P.O. BOX 1504 - LA UUINTA, CALIFORNIA 92253
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FOOM : Panascanic*FAX SYSTEM PHONE NO
Mar. 17 1997 09:09AM P2
J HAVE READ, UNDERSTAND, AND AGREE WITH THE CONDITIONS SY WHICH A HOME
OCCUPATION IS ALLOWED (conditions attached). p
(I/-4'Date
Iicant' Sig ture
IF APP ICANT IS OTHER THAN PROPERTY. OWNER, AUTHORIZATION OF OWNER OR
5--er/Agent
L- - GENT IS Ul
Date
Signature
Agent Company Name
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.
Burt MG & SAFETY DEPARTMENT/CODE COMPLIANCE DIVISION
AfTROVED DENIED SPECIAL CONDITIONS ATTACHED
BY: DATE
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WORKER'S COMPENSATION
If your company has. 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 777-7050.
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 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.
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 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 should become subject to the
worker's compensation provisions of Section 3700, 1 will provide the City with a policy
or certificate copy within ten (10) days of the chang in requirements.
Date: �d /5 ^ �6 Applicant:
WARNING: Failure to secure worker's compensation ccKerage i� unlawf'ul, and sliall subject an
• 'employer to criminal penalties and civil fines up to $100,000. 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.