Wellice..r t • � I llllll VIII I'll Illi
h' 27
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 . P O ��}e, YJ\ees PHONE (fitq)'1'11-0643
PROPERTY OWNER _ PHONE
PROPERTY ADDRESS
MAILING ADDRESS
TYPE OF RESIDENCE
TYPE OF BUSINESS
BRIEF7pgSCRIPTION
"V 'VV/� IrT 1 V!C LY11 \Tl \-R 1 l_/\ -I LGrCJ 7
(single, multiple, mobil home, etc.)
'(HOW THE BUSINESS WILL OPE
L n.! . ) .f t -419 n — . [ qr-O
NUMBF,i PF PERSONS IWOLVED INOUS ESS
1// l "
LIST NAME OF PERSONS EMPLOYED
•
SQUARE FOOTAGE OF USABLE FLOOR AREA
IN HOUSE (EXCLUDE GARAGE) lD/'
SQUARE FOOTAGE OF AREA
LOCATION AND S Q
OF BUSINESS ACTIVITY IN HOME
(EXAMPLE, "BEDROOM -125 S.F.")
DESCRIPTION OF MACHINERY, EQUIPMENT, AND
SUPP IES BEING USED IN TftE
BUSINESS OPERATION
:.. loe
I HAVE READ, UNDERSTAND, AND AGREE WITH
THE CONDITIONS BY WRICH A
HOME CCUPATION IS ALLOWED (CONDITIONS ATTACHED).
APPLICANT SIGNATURE
DATE
IF APPLICANT LS OTHER THAN PROPERTY OWNER,
AUTHORIZATION OF OWNER
OR AGE EQUIRED.
.x
evofzl
9&
WNER/A4�W SIGNATURE
- DATE
IMPORTANT:.. FALSE OR MISLEADING INFORMATION SHALL -BE., GROUNDS FOR
DENYING YOUR ROME OCCUPATION; FAILURE
TO COMPLY WITH CONDITIONS
LISTED ON TETE ATTACHED'PAGE SHALL BE
GROUNDS FOR REVOCATION OF
PERMIT.
.
Bui d n and Safety Department
APPROVED DENIED
CONDITIONS ATTACHED
T4tit 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 sigh 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.
XorJ certify that in the. performance of'any business activities
hich this license is issu
ed l.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 ofN,Section 3700.
Date:, — /$— /� Applicant:
LT'
WARNING: Failure to secure workman's. compensation coverage is
unlawful, and shall subject an employer penalties and
civic fines up to $100,000.- .In� addition- to the cost of
compensation, damages as provided.for•iii'Section 3706 of the Labor
Code', interest, and attorney's,..fees.
: bus.fac
ti
MAILING ADDRESS - P.O. BOX 1504 LA QUINTA, CALIFORNIA 92253 ���: