KUBIK29
• FEE $35.00
- CITY OF LA QUINTA
78-495 Calle Tampico, P. O.Box 1504, La Quinta,
HOME OCCUPATION PERMIT
CA 92253
evl.u.dU1 3
b� $�
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 t4_ �ct,v�� PHONE X564 -/40S
PROPERTY OWNER PHONE S& �,L - /405
PROPERTY ADDRESS ( OQe+ni+,a KI�T� NcZ
MAILING ADDRESS f:?0, g0x kM , 9Zzs-
TYPE OF RESIDENCE (single, multiple, mobil home, etc.)
TYPE OF BUSINESS �vz£2- Re►�«�
BRIEF DESCRIPTION OF HOW THE BUSINESS WILL OPERATE ff ente�-
Pc& �DUS�, iJ�Ss -�OR- Revt�►k,- o,� ll)2 c\ e1, e v1t
NUMBER OF PERSONS INVOLVED IN BUSINESS
• LIST NAME OF PERSONS EMPLOYED
SQUARE FOOTAGE OF USABLE FLOOR AREA
IN HOUSE ( EXCLUDE GARAGE) f2gLvz-,A Z4b S .F,
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
BUSINESS OPERATION PY'0 J
I HAVREAD, UNDERSjrAND, AND AGREE WITH THE CONDITIONS BY WHICH A
HOME�)CCUPATI N -� AIYLOYED ( CONDITIONS ATTACHED) . r
APPWIMANT "S.IYGNATURE DATE
IF APPLICANT IS OTHER THAN PROPERTY OWNER, AUTHORIZATION OF OWNER
OR AGENT IS REQUIRED.
OWNER/AGENT SIGNATURE DATE
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
PERMITif
__________________________________________________________
Building and Safety Department
,..�; APPROVED DENIED CONDITIONS ATTACHED---
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!I(� SEP f P, 19y4 II JI US. LIC. NO.
1994 BUSINESS LICENSE APPLICA*GN PORM 3s f
*APPROVED BY
* DATE
*********** **************
......PROOF OF WORKERS COMPENSATION INSURANCE IS REQUIRED........
IS THIS BUSINESS LOCATED AT YOUR HOME: YES V NO
Business Name:
Business Address: SI %�lO ��f. �'!�(K�11JfZ
4 . Mailing Address: -PO 6ox 110
_QaA 9Z21 c 1, ��v: OA
Business Phone: (—Li]_) C V0
OwnedBy: CORPORATION PARTNERSHIP NDIVIDUAL
If Corporation or Partnership: Tax I.D.#
If Individual Ow er: Soc' a1 Security
Name of Owner �,�� Cal K Title
Or Officers
10. Type of Busine
11. IF YOU ARE A FOOD VENDOR, DO YOU HAVE A COUNTY HEALTH PERMIT:
YES NO �(
12. SBE Resale Number:
13. BUSINESS LOCATED WITHIN THE CITY OF LA QUINTA (Does Not Apply To
Building Contractors):
A. Estimated Gross Business Receipts for New Businesses Only:
$ jC= oo
B. Previous Year Gross Receipts For Established Businesses:
********GOOD ONLY FOR JANUARY 1 1994 THRU DECEMBER 31,1994*******
*******
I HEREBY,CERTIFY thay all the information supplied by me is correct and
any lice ses requir b t County, State or Federal Government have been
issued o me and ar i f 1 force and effect.
z�
igna a Title Date
Submit Form To:
CITY OF LA QUINTA
BUSINESS LICENSE DIVISION
78-495 Calle Tampico
La Ouinta. cA 4278,2
•
-TA'ti�v_ 4 4a Q"
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 .-
r/ 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 :ctJon 3.700.
Date:✓9� �95� Applicant:
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