Borowski72
�• FEE $35.00
•
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CITY OF LA QUINTA
78-495 Calle Tampico, P. O.Box 1504, La Quinta, CA 92253
HOME OCCUPATION PERMIT
Read each condition listed on the attachment to this form to see if
the proposed activity can comply with the City's Home Occupation
Regulations.
BUSINESS NAME ej4jMtJ64 PLUS PHONE 61
PROPERTY OWNER 04RI6ows PHONE / -,SZv {- O 7
PROPERTY ADDRESS , I D• Mt=`7JCDZ-4 L-A Z Z-9-3
MAILING ADDRESS Ayb_ LA CZat PSTyk C.A
TYPE OF RESIDENCE�,.'(�single, multiple mobil home,
C
TYPE OF BUSINESS tIMNG �1►.sE, �c:PAt /L
BRIEF DESCRIPTION OA HOW THE BU ESS WILL ERAT i�.)es;z�a
NUMBER OF PERSONS INVOLVED IN BUSINESS I U
LIST NAME OF PERSONS EMPLOYED N -k
SQUARE FOOTAGE OF USABLE FLOOR AREA
•
IN HOUSE (EXCLUDE GARAGE) LQ20 -:5.4,
LOCATION AND SQUARE FOOTAGE OF AREA
OF BUSINESS ACTIVITY IN HOME .&^-R.Ac$e,
(EXAMPLE, "BEDROOM -125 S.F.")
DESCRIPTION OF MACHINERY, EQUIPMENT, AND SUPPLIES BEING USED IN THE
BUSINESS OPERATION Cci MN�Z4 l 31(�1�%�J 11 i_ �05VI 51 ,�c��S , I� `C7lZ-'iii7_
I HAVE READ, UNDERSTAND, AND AGREE WITH THE CONDITIONS BY WHICH A
HOME OCCUPTI,ONA (GOND TTLA7
CHED) .a
APPLICANT SIGNA'
IF 'APPLICANT IS OTHER THAN PROPERTY OWNER, _XtftR6R.IZATIdJR -OF ". I &.- ;
OR AGENT IS REQUIRED.
OWNER/AGENT SIGNATURE DATE
IMPORTANTt9
. FALSE OR MISLEADING INFORMATIO-SHALI BE GROUNDS
DENYING YOUR HOME OCCUPATION; FAILURE TO COMPLY hFY ? CONDITIONS; ;
LISTED ON THE ATTACHED PAGE SHALL .,BE- GROWDS TOR-. REVOCATION OF i-` .
„HERMIT.
Buildin -•.and Safety Department _.
4/7 APPROVED DENIED ,;. COIe9X)ITIONS ATTACHED
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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.
• My worker's compensation insurance carrier and policy number:
Carrier:
Policy Number:
A "COPY" -OF THE POLICY SHOWING THE AMOUNT OF COVERAGE AND
EXPI_RATION DATE FOR WORKMEN'S COMPENSATION IS-REOUIRED TO'PROCESS
THIS APPLICATION.
✓ 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 Section 3700.*'
Date:LP Applicant: GL- L---
WARNING: Failure to secure workman's compensation .coverage is
unlawful, and shall subject an employer to criminal penalties And., u.,
civic fines up to $100,000. In addition to the cost. of ,
compensation, damages'°,as provided for in.Section,3706 of the Labor-.• 1m+
Code, interest, and attorney's fees. _ �'�
. ...� : bus . fac
MAILING ADDRESS - P.O. BOX 1504-- LA OUINTA, CALIFORNIA 92253
071