BRUNER• 12
FEE $35.00 i�` I,21MMly
CITY OF LA QUINTA
78-495 Calle Tampico, P. O.Box 1504, La Quinta, CA 92253
r
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 ' PHONE
PROPERTY OWNER n j.4 PHONE G/ –
PROPERTY ADDRESS
MAILING ADDRESS Qalbl 1914ZAIAVO, e,4(
TYPE OF RESIDENCE. (single, multiple, mobil home, etc.) zt-
TYPE OF BUSINESS
BRIEF DESC IP ION F HOW THE BUSINESS W OPERATE LAS'
OD �2 & v M it -,e . .V
NUMBER OF PERSONS INVOLVED IN BUSINESS 0
LIST NAME OF PERSONS EMPLOYED O/u' c�
SQUARE FOOTAGE OF USABLE FLOOR AREA
IN HOUSE (EXCLUDE GARAGE)
• LOCATION AND SQUARE FOOTAGE OF AREA
OF BUSINESS ACTIVITY IN HOME
(EXAMPLE, "BEDROOM -125 S.F.")
DESCRIPTION OF MACHINERY, EQUIPMENT, AND SUPPLIES B ING USED IN THE
BUSINESS OPERATION c
x e_>4
I HAREAD, UNDERSTAND, AND AGREE WITH THE CONDITIONS BY WHICH A
HOME 0 CUPATION IS ALLOWED (,rgNDITIONS CHED).
--
P ICANT SIGNATtME DATE
-
Is" APPLICANT AIS OTHER '71 A— PROPER711,1' aW-NER, AUTHORIZATION'=10li_GWkkN �
GENT I REQUIRED._ T,., ...
/67
0 }/AGENT. SIGNA E -� �1. �.. TE �S h.
IMPORTANT: FALSE OR MISLEADING IkFORMATION SHAII B1?-L%JRMJNDS tO rq
DENYING YOUR HOME OCCUPATION; FAILURE TO COMPLY:,. WITAV,% *��I}NS�
LISTED ON THE '�ATTA�HEp P1�Q 'µSHA1:Y:.�E GROUNDS ::F® '.kkfd Alift AW
PERMIT. "-
��_________________________________�z=====_________=�`-'�=_____--
Building and Safety -.Department
PROVED-. DIED CONDITIONS �"TAC HED C.HE
APR 1 r 1996
•
4
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 Section 3700.
.Date: —��1_ Applicant:
WARNING: Failure to secure workm 's compensation coverage is
unlawful, and shall subject an emp oyer 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 QUINTA, CALIFORNIA 92253