PICKAVANCE (2)1.
'4� 22 Atyl
` BUS. LIC. NO.
1995 BUSINESS LICENSE APPLICATION FORM
*APPROVED B /
* DATE/
************** **** ******
PROOF OF WORKERS COMPENSATION INSURANCE IS REQUIRREED PRIOR TO ISSUANCE
IS THIS BUSINESS LOCATED AT YOUR HOME: YES ✓ NO
2. Business Name: �►'�-�PiC YtGi U_ SY�I�(� Lac 4, SYyy,AQ_�ts,
S1s3S Ave 1�j
3. Business Address: Dbye 4. Mailing Address
o� l/c_ A4 -bo pdy�, -Aox,& a 9 zZb 0
5. Business Phone: . ( ) 564- 26 25
6. Owned By: CORPORATION PARTNERSHIP C INDIVIDUAh
7. If Corporation or Partnership: TAX I.D.#
8. If Individual Owner: Social Security # S4-6 - 33—
9. Name of Owner ZsDc�P_11i CICG �C�Vt Title: Co - (�(,�
Or Officers Co - pyprpA l a� GM�
0,0. Type of Business: _XD _C_ Sn 5 "x7bLa n 1� n L&+i
11. IF YOU ARE A FOOD VENDOR, DO YOU HAVE A COUNTY HEALTH PERMIT:
YES NO
12. SBEResale Number:
13. BUSINESS LOCATED WITHIN THE CITY OF LA QUINTA (Does Not Apply To Building
Contractors):
A. Estimated Gross Business Receipts for New Businesses Only:
$ 120 , o o -o
B. Previous Year Gross Receipts for Established Businesses:
***********GOOD ONLY FOR JANUARY 1, 1995 THRU DECEMBER 31, 1995**********
I HEREBY CERTIFY that all the -information supplied by me is correct and any
licenses required by the County, State or Federal Government have been issued
to me n e in full force and -effect.
Is lqs
i ture Title Date
• Send Completed Form To:
CITY OF LA QUINTA
BUSINESS LICENSE DIVISION
78-495 Calle Tampico
P. 0. Box 1504
La Quinta, CA 92253
0
Ct, t�,Lf-LrGv
• FEE $35.00
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 -E5-kfF'lGl,}i6YW rlDl� CDr-&UA+Oy NE (e1) 56-4 - S IDS
PROPERTY OWNER S + catjd4 IG roc.- PHONE SC-,�} - Z 6 Z S
PROPERTY ADDRESS s i S q?,aS3
MAILING ADDRESS P • D • 66X I IS�13 ,Al►+. Ccz 9 a'a SS
TYPE OF RESIDENCE (single, multiple, mobil home, etc.) s� hco
TYPE OF BUSINESS C-Ic,\-( insit'udt�+� C)Uktivtiw
BRIEF DESCRIPTION OF HOW THE BUSINESS WILL OPERATE
C -I o 4 i MAA -;0
LOCATION AND SQUARE FOOTAGE OF AREA
OF BUSINESS ACTIVITY IN HOME 40 S.�
(EXAMPLE, "BEDROOM -125. S.F.")
DESCRIPTION OF MACHINERY, EQUIPMENT, AND SUPPLIES BEING USED IN THE
BUSINESS OPERATION
I HAVE READ, UNDERSTAND, AND AGREE WITH THE CONDITIONS BY WHICH A
unmr- ncCtIPATr in IS_ ALLOWED ( CONDITIONS ATTACHED) .
APPLICANT SIGNATURE prr-r-" M-r'lr�
! i6
ATE
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.
• Bu di and--of---=De artment__________________________________
APPROVED DENIED CONDITIONS ATTACHED
NUMBER OF
PERSONS
INVOLVED IN -BUSINESS 2- -
LIST NAME
OF PERSONS EMPLOYED rl n r,p- tSwhtd Com,,,
•
SQUARE FOOTAGE OF
USABLE FLOOR AREA
IN HOUSE
(EXCLUDE
GARAGE) —
LOCATION AND SQUARE FOOTAGE OF AREA
OF BUSINESS ACTIVITY IN HOME 40 S.�
(EXAMPLE, "BEDROOM -125. S.F.")
DESCRIPTION OF MACHINERY, EQUIPMENT, AND SUPPLIES BEING USED IN THE
BUSINESS OPERATION
I HAVE READ, UNDERSTAND, AND AGREE WITH THE CONDITIONS BY WHICH A
unmr- ncCtIPATr in IS_ ALLOWED ( CONDITIONS ATTACHED) .
APPLICANT SIGNATURE prr-r-" M-r'lr�
! i6
ATE
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.
• Bu di and--of---=De artment__________________________________
APPROVED DENIED CONDITIONS ATTACHED
T4hf 4 4a_Qu41k&
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.
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 sho d become subject to
the worker' compensation provisions of 0 3700.
Date: ZApplicant:
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