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FEE $35.00
CITY OF LA QUINTA
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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 C'h
PROPERTY OWNER 7DaA,
PROPERTY ADDRESS - 1
MAILING ADDRESS
TYPE OF RESIDENCE singl
TYPE OF BUSINESS
BRIEF DESCRIPTION OF HOW
PHONE (PI 56 y-a9�3
PHONE IsAMF-
Itiple, mobil home, etc.)
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N MBER OF PERSONS INVOLVED IN BUSINESS l I _oeA"CLorI�
LIST NAME OF PERSONS EMPLOYED — O+
SQUARE FOOTAGE OF USABLE FLOOR AREA
IN HOUSE (EXCLUDE GARAGE) b O
LOCATION AND SQUARE FOOTAGE OF AREA
OF BUSINESS ACTIVITY IN HOME
(EXAMPLE, "BEDROOM -125 S.F.")
DESCRIPTION OF MACHINERY, EQUIPMENT, AND SUPPLIES SING US D IN THE
BUSINESS OPERATION 0-.&m prA-her , +e-)e:&&y) e.. -4-; Ic-. C0of ale-+
I HAVE READ, UNDERSTAND AND AGREE WITH THE CONDITIONS BY WHICH A
HOME OCATIA ( CONDITIONS ATTACHED) . 3� 5�/9O
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
PERMIT. .
-
uil4inq and Safety Department Jh m:
APPROVED DENIED CONDITIONS ATTACHED.,:
NEAR 19
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78-495 CALLE TAMPICO — LA OUINTA, CALIFORNIA 92253 - (619). 777-701
FAX (619) 777-710
Dear Business Owner:
If your company has employees, a copy of.the workman's
compensation policy must accompany the business license
application, indicating dates of coverage and dollar amount.
This proof.of coverage must be received before the business
license can be processed.
If you do not have employees; please check the -last line on the
first page: "I certify that....
If'your. business is being operated from your home in La Quinta, a
Home Occupation_Permit is required before.a business license is
issued. Approval of the Home Owners Association is also required
if you live in a gated community.
If -you have any questions, please contact me.
Sincerely,
Ellie Shepherd
Building.& Safety.
buslic.hoc
MAILING ADDRESS - P.O. BOX 1504 LA. OUINTA; CALIFORNIA 92253
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78-495 CALLE TAMPICO - LA OUINTA, 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.
I
My worker's compensation insurance carrier and policy number:
Carrier:
Policy Number:
A "COPY" OF THE POLICY SHOWING THE AMI
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ON.
ENSATION I
OF COVERAGE AND
JIRED TO PROCESS
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 a's 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: Applicant: AaadQ--�
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 AOORESS - P.O. BOX 1504 - LA OUINTA, CALIFORNIA 92253 ��!