MONTEZ•
•
FEE $35.00
CITY OF LA QUINTA
78-495 Calle Tampico, P. O.Box,1504, La Quinta, CA 92253
J.
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 LL�C.�J PHONE W -0, -O O
PROPERTY OWNER -6a WA. PHONE -15Q
PROPERTY ADDRESS-
MAILING ADDRESS
TYPE OF RESIDENCE (single, multiple, mobil home, et .)
TYPE OF BUSINESS
BRIF�F DESCPIPTION OF HOW �E�U� NESS OPERATE
l
NUMBER OF PERSONS INVOLVED IN BUSINES
LIST NAME OF PERSONS EMPLOYED &K,66r AAw /z" p I mw -r,-
SQUARE FOOTAGE OF USABLE FLOOR AREA
IN HOUSE ( EXCLUDE GARAGE) -F660 5,F-
LOCATION
),F-
LOCATION AND SQUARE FOOTAGE OF AREA (��(
OF BUSINESS ACTIVITY IN HOME L
( EXAMPLE , "BEDROOM -12 S. S. F.
DESCRIPTION OF MACHINE EQUIPM NT, AND SUPPLIES BEING USED IN
BUSINESS OPERATION 9SfK/� �'dV�/� % 5-- � �Akl/ <Ael&
I *VT READ, UNDERSTAND, AND AGREE WITH THE CONDITIONS BY WHICH A
Hq cgyP,ITAq �F OWED (CONDITIONS ATTACHED).,/
S
IF �PLICANT IS OTHER THAN PROPERTY OWNER, AU'1'f:OR_IZATTDN DE ER
0 EMM IS ffW11 �ER. '
IMPORTANT: FALSE OR MISLEADING INFORNA TION SHALL ', .G UMDS FOR
DENYING YOUR FTOME OCCUPATION; FAILURE .'f0 COMPLY"
M010
TIONS
LISTED ON THE ATTACY�6 � PAGE SHALL BE tRODS FOR 4,.ON OF
PERMIT. a
ld n �a'nd Safety Department
V1 Aj; "PROVED DENIEDw CONDITIONSIACHED-
APJI., 1996
•
.c.�` 78-495 CALLE TAMPICO — LA OUINTA, CALIFORNIA 92253 (619). 777.
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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Tdit 4 4a Qumt-
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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 37.00 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.
I certify that in the performance of any business activities
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 ction 370 .
.Date: '2' U 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