RASCON1111111 IIIII IIII IIII
65
FEE $35.00
�8-495
CITY OF LA QUINTA
Calle Tampico, P. O.Box 1504, La Quinta, CA 92253
HOME OCCUPATION PERMIT
Read each condition listed on the attachment to this form to see if
the proposed activity can comply with the City's Home Occupation
Regulations.
BUSINESS NAME
PROPERTY OWNER
PROPERTY ADDRESS
MAILING ADDRESS.
TYPE OF RESIDENCE (sij
TYPE OF BUSINESS �1
BRIEF DESCRIPTION OF i
>�ZPIibNE
w� PHONE
e, multiple, mobil home, etc.)
THE BUSINESS WILL OPERATE
NUMBER OF PERSONS'INVOLVED IN BUSINESS
LIST NAME OF PERSONS EMPLOYED/
SQUARE FOOTAGE OF USABLE FLOOR AREA � �orQ�e
IN HOUSE (EXCLUDE GARAGE) �� v
LOCATION AND SQUARE FOOTAGE OF AREA
OF BUSINESS ACTIVITY IN HOME
(EXAMPLE, "BEDROOM -125 S.F.")
DESCRIPTION OF MACHINERY, EQUIPMENT, AND SUPPLIES BEING USED IN THE
BUSINESS OPERATION / y ,�
, ✓t �c� 1-,
I HAVE READ, UNDERSTAND, AND AGREE WITH THE CONDITIONS BY WH CH A
HOME OCCUPAI N IS L'LOWED (CONDITIONS ATTACHED).
A PLICANT SIGNATURE `DATE/
IF APPLICANT IS OTHER THAN PROPERTY OWNER, AUTHORIZATION OF..OFINER
OR AGENT IS REQUIRED.
"TOPS z
.{ OWNER/AGENT SIGNATURE " DATE
IMPORTANT: FALSE OR MISLEADING. INFORMATION .$HALL-" 3E G�OUNDS FOR
DENYING YOUR HOM OCCUPATION; FAIL IRE. TO CO l Y , W m ONDITIONS ,.
LISTED ON THE `�'i�I'TACHED . :AGE SiYAI.f: ` BF GROUNFlS AOR•• REVOCATION OF.-,
PERMIT.�s_'
F'�•• ' tP.i.i.. t
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H din- rated Sa ;"� � ?drtment - � - A,
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jAPPRO `u i�"s� DENIED CaDITIONS='.A TTACHED
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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 THE AMOUNT OF COVERAGE AND
EXPIRATION DATE FOR WORKMEN'S COMPENSATION IS REQUIRED TO PROCESS
THIS APPLICATION.
X I certify that in the performance of anv 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 Sect' -on 3700.
Date: / 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.
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MAILING ADDRESS - P.O. BOX 1504 - LA OUINTA, CALIFORNIA 92253 \;(.