LIPPER• FEE $35:00
CITY OF LA QUINTA
78-495 Calle Tampico, P. O.Box 1504,
pi -5V 3 0
La Quin a, CA 92253
HOME OCCUPATION PERMIT
Read each condition listed on the attachment to this form to see if
the proposed activity can comply with the City's Home Occupation
Regulations.
BUSINESS NAME (.APA -D WM 1007r�,6PHONE (0/9 -S(-Y- y/5/$ -
PROPERTY OWNER PAMELA L iPP£e. PHONE (o 19 - S (a y- tf/ SSS
PROPERTY ADDRESS ?SfoBS Avi X -A Toffs Lig 0w.,k/7-74 9aa5-3
MAILING ADDRESS -,5-Am L
TYPE OF RESIDENCE (single, multiple, mobil home, etc.)
TYPE OF BUSINESS 000TiF e --
BRIEF DESCRIPTION OF HOW THE BUSINESS WILL OPERATE A)9--,, y0orn.2v
A --r -it5y►, c 1�1 o ~k K i r ) T A 7- G92 T S ){� A IJJD Y�)q i /2 S
NUMBER OF PERSONS INVOLVED IN BUSINESS I
LIST NAME OF PERSONS EMPLOYED A!o.41
• SQUARE FOOTAGE OF USABLE FLOOR AREA
IN HOUSE ( EXCLUDE GARAGE) x850
LOCATION AND SQUARE FOOTAGE OF AREA
OF BUSINESS ACTIVITY IN HOME 09770 X00
( EXAMPLE , "BEDROOM -125 S.F.") OPF, C E, (�✓n i s y RooM�
DESCRIPTION OF MACHINERY, EQUIPMENT, AND SUPPLIES BEING USED IN THE
BUSINESS OPERATION Po7t'e-)?- Y -)-n6 (eL , 6 L Ar6 R01 -L4..4— , C4 -/9k/
I HAVE READ, UNDERSTAND, AND AGREE WITH THE CONDITIONS BY WHICH A
HOME ACCUPATION IS ALLOWED ( CONDITIONS ATTACHED) .
_ -
APPLICAfftSIONATURE .DATE
-
;; IF APPLICANT IS OTHER THAN PROPERTY OWNER, AUTHORIZATION OF•OWNER
OR AGENT IS REQUIRED.
OWNER/AGENT SIGNATURE
DATE
CORTANT : °FALSE Oit MIS INFOF�MATION SHALL�j HE GROUNDSFOR
YINO -YOUR';:,HOME _ OCCUPA ' AI TO'' COMPLY ;WITH CONDITIONS
,LUTED ON THE ATTACHED PAGE SHALL BE GROUNDS FOt'wREVOCA-ftON ,,OF
* 81ii n and Safet v De artmdnt -
.3 APPROVED DENIM. CONDITIONS ATTACHED
l
I%r
75
• FEE $35:00
CITY OF LA QUINTA
78-495 Calle Tampico, P. O.Box 1504,
pi -5V 3 0
La Quin a, CA 92253
HOME OCCUPATION PERMIT
Read each condition listed on the attachment to this form to see if
the proposed activity can comply with the City's Home Occupation
Regulations.
BUSINESS NAME (.APA -D WM 1007r�,6PHONE (0/9 -S(-Y- y/5/$ -
PROPERTY OWNER PAMELA L iPP£e. PHONE (o 19 - S (a y- tf/ SSS
PROPERTY ADDRESS ?SfoBS Avi X -A Toffs Lig 0w.,k/7-74 9aa5-3
MAILING ADDRESS -,5-Am L
TYPE OF RESIDENCE (single, multiple, mobil home, etc.)
TYPE OF BUSINESS 000TiF e --
BRIEF DESCRIPTION OF HOW THE BUSINESS WILL OPERATE A)9--,, y0orn.2v
A --r -it5y►, c 1�1 o ~k K i r ) T A 7- G92 T S ){� A IJJD Y�)q i /2 S
NUMBER OF PERSONS INVOLVED IN BUSINESS I
LIST NAME OF PERSONS EMPLOYED A!o.41
• SQUARE FOOTAGE OF USABLE FLOOR AREA
IN HOUSE ( EXCLUDE GARAGE) x850
LOCATION AND SQUARE FOOTAGE OF AREA
OF BUSINESS ACTIVITY IN HOME 09770 X00
( EXAMPLE , "BEDROOM -125 S.F.") OPF, C E, (�✓n i s y RooM�
DESCRIPTION OF MACHINERY, EQUIPMENT, AND SUPPLIES BEING USED IN THE
BUSINESS OPERATION Po7t'e-)?- Y -)-n6 (eL , 6 L Ar6 R01 -L4..4— , C4 -/9k/
I HAVE READ, UNDERSTAND, AND AGREE WITH THE CONDITIONS BY WHICH A
HOME ACCUPATION IS ALLOWED ( CONDITIONS ATTACHED) .
_ -
APPLICAfftSIONATURE .DATE
-
;; IF APPLICANT IS OTHER THAN PROPERTY OWNER, AUTHORIZATION OF•OWNER
OR AGENT IS REQUIRED.
OWNER/AGENT SIGNATURE
DATE
CORTANT : °FALSE Oit MIS INFOF�MATION SHALL�j HE GROUNDSFOR
YINO -YOUR';:,HOME _ OCCUPA ' AI TO'' COMPLY ;WITH CONDITIONS
,LUTED ON THE ATTACHED PAGE SHALL BE GROUNDS FOt'wREVOCA-ftON ,,OF
* 81ii n and Safet v De artmdnt -
.3 APPROVED DENIM. CONDITIONS ATTACHED
l
"' `��� 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 AMI
EXPIRATION DATE FOR WORKMEN'S COMPENSATION I:
COVERAGE AND
TO PROCESS
THIS PLICATION.
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 ofS ion 37
Date: ?-do- y'_ applicant: P
WARNING: 'Failure to secure workman's compensa ion 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 ���.