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HAMPTON (2)• � / I I I' I I' V I I I I"I I I I I \ 37 • 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 NAME A 455A6C PHONE Slpy�gq PROPERTY OWNER �a v- S e\ PHONE PROPERTY ADDRESS 549-K K E :j -y Pr7-- L& Q 0f►1 q 115 MAILING ADDRESS f A -4M TYPE OF RESIDENCE QLjp5lo, multiple, mobil home, etc.) TYPE OF BUSINESS rVk GA 5 5 4-61 e-, BRIEF DESCRIPTION OF HOW THE BUSINESS WILL OPERATE NUMBER OF ERSONS INVOLVED IN BUSINESS :�L LIST NAME OF PERSONS EMPLOYED OSI crW e - SQUARE FOOTAGE OF USABLE FLOOR AREA----""(�- • IN HOUSE ( EXCLUDE GARAGE) (0O LOCATION AND SQUARE FOOTAGE OF AREA FEBX95 U OF_BUSINESS ACTIVITY IN HOME ( EXAMPLE , . "BEDROOM -125 S.F.") 3ed r6ov� t 5'0 5 ` DESCRIPTION OF MACHINERY, EQUIPMENT, AND SUPPLIES BEING -USED IN'THE BUSINESS OPERATION Mri 55 0.A 2 +o o ( `� I HAVE READ, UNDERSTAND, AND AGREE WITH THE CONDITIONS BY WHICH A HOME CC ATIO IS AL, OWED (CONDITIONS ATTACHED). APPLICANT SI NATURE DATE IF APPLICANT IS OTHER THAN PRO OR AGEVT—I`5 REQOIRED. Z'-) / AGENT , AUTHORIZATION OF OWNER 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. • Buildin d Safety Department APP OV D DENIED CONDITIONS ATTACHED 41 T4t�t 4 4a QuiKt 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 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 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: ' `�"' �S Applicant: U r—ME-11 J 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 ADDRESS - P.O. BOX 1504 - LA QUINTA, CALIFORNIA 92253