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• FEE $35.00
CITY OF LA QUINTA
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 NAMEr n _ i C�HONE h l g -Shy -5119
PROPERTY OWNER
PHONE
PROPERTY ADDRESS - o- A 77
MAILING ADDRESS
TYPE OF RESIDENCEsin le, mult• le, mobil home, etc.) e
TYPE OF BUSINESS ;
BRIEF DESCRI T NOF HOW THE BUSINESS ILL OPERATE rYl S
t �l YX `
NUMBER OF PERSONS INVOLVED qN BZj INESS
LIST NAME OF PERSONS EMPLOYED , sLl1ti
SQUARE FOOTAGE OF USABLE FLOOR AREA
• IN HOUSE ( EXCLUDE GARAGE) / LO S •�'
LOCATION AND SQUARE FOOTAGE OF AREA
OF BUSINESS ACTIVITY IN HOME
(EXAMPLE, "BEDROOM -125 S.F.")
DESCRIPTION OF MACHINERY, EQUIPMENT, AND SUPPLIES BEING USED IN THE
BUS NESS OPERATION llaeCo /}yam r �ij jrn /'QAC and (11iA'7qV C
I HA70JA
41), DERSTAND, AND AGREE WITH THE CONDITIONS BY WHICH A
HOMEC U A7I0j 1. pIS ^ ALLQWED ( CONDITIONS ATTACHED) . 9.9l_
IF APPLICANT IS OTHER THAN PROPERTY OMER, AUTHORIZATION OF -OWNER
OR AGENT IS REQUIRED. .. •.
.:'rte•. bap •.. a .. ..
OWNER/AGENT SIGNATURE '-AATE
IMPORTANT: FALSE OR MISLEADING INFOR '.TION SHALL BE GROUNDS. FOR
DENYIN.q. YOUR HOME OCCUPATION; FAILURE.,TO C WLY ;.TITh CONDITIONS
LISTEDAJON THE ATTACHED PAGE SHALL BE WOUi+T1 F'P REVOCATION OF
PERMIT.;
B 1 in -,Safet De artmentF -
Ar? bVED DED _ COND clfS A'ITAC1r%
CA
APeR:O a 1996
` Rv
•
•
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 "
ANn
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 Sec inn 37 0.
.Date : Applicant:
WARNING: Failure to secure workman's com nsation 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 OUINTA, CALIFORNIA 92253
4
BUS. LIC. NO
v C/
1996 BUSINESS LICENSE APPLICATION FORM
****************** **** ************** ********
* APPROVED BY DATE 44-41 "
*************** * * *****************************
PROOF OF WORKERS COMPENSATION INSURANCE IS REQUIRED PRIOR TO ISSUANCE
1. IS THIS BUSINESS LOCATED AT YOUR HOME: YES i,-' NO
2. Business Name:
3. Business Address: . 9"Ye ra 4. Mailing Address
5. Business Phone:
6. Owned By: CORPORATION PARTNERSHIP NDIVIDU
7. If Corporation or Partnership: TAX I.D. #
8. If Individual Owner:
Social Secur/ity1# !SS 3
-7 3 -7 35 7
9. Name of Owner
P .�Q Yl i A (1Cly'1S(3-.
Title: TrCLIAV"c�
or Officers
• 10. Type of Business:
-- -11. IF YOU ARE A FOOD VENDOR, DO YOU HAVE A COUNTY HEALTH PERMIT:
YES NO
12. SBEResale Number:
13. BUSINESS LOCATED WITHIN THE CITY OF LA QUINTA (Does Not Apply To Building Contractors):
A. Estimated Gross Business Receipts for New Business Only:
$ �oi�00
B. Previous Year Gross Receipts for Established Businesses:
******************GOOD ONLY FOR JANUARY 1, 1996 THRU DECEMBER 31,1996***************
I HEREBY CERTIFY that all the information supplied by me is correct and any licenses required by the County, State
or Federvil Poverrunetrt have been issued to me and are in full force and effect.
1_
S atur Title Date
Send Completed Form To:
CITY. OF LA QUINTA
BUSINESS LICENSE DIVISION
78-495 Calle Tampico
P.O. Bot 1504
La Quinta, CA 92253
BUSINESS LOCATED IN THE CITY OF LA QUINTA ONLY
GROSS RECEIPTS
RANGE
CLASS 1 CLASS 2D CLASS 3
0
- 25,000
$ 15.00 18.0 $ 21.00
25,001
- 50,000
25.00 30.00 36.00
50,001
- 100,000
30.00 6.00 43.00
100,001
- 250,000
46.00 55.00 66.00
250,001
- 500,000
76.00 90.00 108.00
500,001
- 750,000
114.00 135.00 162.00
750,001
- 1,000,000
150.00 180.00 216.00
1,000,001
- 2,000,000
400.00 500.00 600.00
2,000,001
- 3,000,000
500.00 625.00 750.00
3,000,001
- 4,000,000
600.00 750.00 900.00
4,000,001
- 5,000,000
700.00 875..00 1,050.00
51000,001
- 101000,000,
1,000.00 1,250.00 1,500.00
10,000,001
- and up
1,500.00 1,875.00 2,250.00
CLASS 1
Automobile Repair
and Services; Laundry,.Dry Cleaning & --
Garment Services;
Manufacturing; Retail & wholesale
Trade.
CLASS 2
Amusement & Recreation
Services, including Motion
Pictures; Architectural
Services; Automotive Sales;
Barbers & hairstylists;
Beauty Shops; Engineering
Services; Landscape & horticultural Services; Operators
Renters & Lessors
of Commercial Property; Services to
Buildings; and all other persons engaged in business
not specifically
listed elsewhere.
CLASS
Accounting, Auditing & Bookkeeping Services; Financial
Services; Insurance Brokers & Services; Legal Services;
Management & Public Relations Services; Medical &
Health Services;
Real Estate Agents, Brokers, Managers
& Services.