DRURY41
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• FEE $35.00
CITY OF LA QUINTA
78-495 Calle Tampico, P. O.Box 1504, La Quinta, CA 92253
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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. 1 he perPHONE
PROPERTY OWNER Dan YYlpinn�P_S�rctrc_ PHONE CibL# 1-4k1S
PROPERTY ADDRESS c;t4c34ZS 4\�(!- MP4\M. ;,d LCa n,L�LnVCA CCS
MAILING ADDRESS qq,�1yq -v7Suarn C- W\i 5 . On.
TYPE OF RESIDENCE ( in multifle mobil home, etc.)
TYPE OF BUSINESS l \(fin WkU(�-P O'l 5mcm d, - t�
BRIEF DESCRIPTION OF HOW THE BUSINESS WILL OPERATE •1
3. r� -�40 1- z r ,.
NUMBER OF PERSONS INVOLVED IN BUSINESS
LIST NAME OF PERSONS EMPLOYED iy\�
SQUARE FOOTAGE OF USABLE FLOOR AREA
IN HOUSE (EXCLUDE GARAGE) JILD 5R��
14/1V 14,0
LOCATION AND SQUARE FOOTAGE OF AREA S%
OF BUSINESS ACTIVITY IN HOME
( EXAMPLE , "BEDROOM -125 S.F.")
DESCRIPTION OF MACHINERY, EQUIPMENT, AND SUPPLIES BEING USED IN`
BUSINESS OPERATION a- - ,00
LrU
I HAVE READ, UNDERSTAND, AND AGREE WITH��THE CONDITIONS BY ICH A'
HOME OCCUPATION IS ALLOWED (CONDITIONS ATTACHED
APPLIC NT SIGNATU 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
PERMIT.
• Build n and_Safety Department
APPROVED DENIED CONDITIONS ATTACHED
14
4�4
78-105 CALLE ESTADO — LA QUINTA. CALIFORNIA 92253 - (619) 564-2246
FAX . (619) 564-5617
Dear Business License Applicant:
Every employer who applies for any license or for 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 the states the following
WORKERS' 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 workers' compensation, as_provided by Section 3700,
for the duration of any business activities conducted for
which this license is issued.
I nave and will maintain worker's compensation insurance, as
required by Section 3700, for the duration of any business
activitie$ conducted for which this license is issued.
•. My,workers, compensation insurance carrier and policy number
are:
Carrier
•
Policy Number
ZI 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. workers'
compensation laws of California, and agree that if I should
become subject to the workers' compensation provisions of
Section 3700'of the Labor Code, I shall forthwith comply with
the.provisions of Section 3700.
Date: Applicant: - Y/t 10�",,l/)A
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS
UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL'PENALTIES AND
CIVIL 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..
MAILING ADDRESS - P.O. BOX 1504 - LA QUINTA, CALIFORNIA 92253