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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 ffZ0quC(5r0 D S tc,"S PHONE 6tV l i I-OaZy
PROPERTY OWNER F'p0.Kc.iSto 4�SLt_�ec(FZ PHONE 771-qLZz
PROPERTY ADDRESS _TZ^o-jd 4ye, /L�t9KTE2u•. rc/
MAILING ADDRESS 9,0_ 60K 15-36 CA C?,ct-,7 ,4 c4 9 7-z S 3
TYPE OF RESIDENCE (single, multiple, mobil home, etc.)
TYPE OF BUSINESS "ie -CHI 7'E CT ti0f,4,- SfRvtc-
BRIEF DESCRIPTION OF HOW THE BUSINESS WILL OPERATE
NUMBER OF PERSONS INVOLVED IN BUSINESS /W_r--4e1=
LIST NAME OF PERSONS EMPLOYED iliC"C e-
SQUARE FOOTAGE OF USABLE FLOOR AREA
IN HOUSE ( EXCLUDE GARAGE) 2 6 oO /P
LOCATION AND SQUARE FOOTAGE OF AREA
OF BUSINESS ACTIVITY IN HOME Z�
(EXAMPLE, "BEDROOM -125 S.F.")
DESCRIPTION OF MACHINERY, EQUIPMENT, AND SUPPLIES BEING USED IN THE
BUSINESS OPERATION 7y,g rve c TEA_ F.4,c
I HAVE READ, UNDERSTAND, AND AGREE WITH THE CONDITIONS BY WHICH A
HOME OCCUPATION IS ALLOWED (CONDITIONS ATTACHED).
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APPLICANT SIGNATURE DATE
IF APPLICANT IS OTHER THAN PROPERTY OWNER, AUTHORIZATION OF OWNER
OR AGENT IS REQUIRED.
OWNER/AGENT SIGNATURE •. A DATE
IMPORTANT: FALSE OR 'MISLEADING INFORMATION SHALL BE GROUNDS—FOR
DENYING YOUR HOME OCCUPATION; FAILURE TO COMPLY WITH CONDITIONS
LIS'T'ED ..ON THE ATTACHIF:D PAGE SHALL BE- dROT.317WS FOR'' REVOCATION OF
PERM 141' }
�D ld n and Safety A, artme�tt
APPROVED DENI �_ CONPXTX..Omi ATTACHED
. u;�• ��� '_ ..:MAR 1 1S
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78-495 CALLE TAMPICO — LA OUINTA, CALIFORNIA 92253 - (619). 777-70►
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,la
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 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 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
EXPIRATION DATE FOR WORKMEN'S COMPEN;
THIS APPLICATION.
COVERAGE AND
S REQUIRED TO PROCESS
I certify that in the performance of any business activities
1—r 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: 3 ^ %� Applicant:
WARNING: Failure to secure workman's compensation cover ge 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
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MAILING ADDRESS - P.O. BOX 1504 LA OUINTA, CALIFORNIA 92253 "
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