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CITY OF LA QUINTA
-78= a11e.Tampico, P. O.Box 1504, La Quinta, CA 922
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 (w PHONE (Gi9) 5-6Z/- 0,4/1t4,
PROPERTY OWNER v PHONE
PROPERTY ADDRESS S`IS4s Ai.0 g4 ME /
MAILING ADDRESS S44-^ -e-
TYPE OF RESIDENCE (single, multiple, mobil home, etc.)
TYPE OF BUSINESS. e '4F(),q t/1►1 4
BRIEF DESCRIPTION OF HOW THE BUSINESS WILL OPERATE (Ari 0
NUMBER OF PERSONS INVOLVED✓IN BUSINESS
LIST NAME OF PERSONS EMPLOYED "/ G J v1�d2/G L f
SQUARE FOOTAGE OF USABLE FLOOR AREA
IN HOUSE (EXCLUDE GARAGE)
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 —, o Ltj&5r c 0 2 ecl e�rJ ei_ Pc -c. e.A-. 4 ri-el
I HAVE READ, UNDERSTAND, AND AGREE WITH THE CONDITIONS BY WHICH A
HOME OCCUPATION IS ALLOWED (CONDITIONS ATTACHED)._ZZ
s CJ
A&PLICANT SIGNATURE 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
PERMI .
• B_=1=in==and Safety Department
APPROVED DENIED CONDITIONS ATTACHED
1995 BUSINESS LICENSE APPLICATION FORM
*APPROVED BY
* DATE S- -
PROOF OF WORKERS COMPENSATION INSURANCE IS REQUIIRRED PRIOR TO ISSUANCE
IS THIS BUSINESS LOCATED AT YOUR HOME: YES (/ NO
BUS. LIC. NO.
Business Name: FS421, / &QfI /�I/Gy�L
Business Address:,5/9.40WIPU7 4. Mailing Address: -c�4,.�
5.
Business
Phone:
6.
Owned By:
CORPORATION
PARTNERSHIPINDIVIDUAL
7. If Corporation or Partnership: TAX I.D.#
8.
9.
If Individual Owner: Social Security # ,�j e -11-0609
Name of Owner dzj6y.e_'4 AGN2/dafrn Title:
Or Officers
Type.of Business:
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:
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 and are in full force and effect.
v AA=
S' nature Title
• Send Completed Form To:.
CITY OF LA QUINTA
BUSINESS LICENSE DIVISION
78-495 Calle Tampico
P. O.. Box 1504
La Quinta, CA 92253
to
'78495 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 REOUIRED 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•should become subject to
the worker's compensation provisions of'Section 3700.
Date: CSS//c� 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 OUINTA, CALIFORNIA 92253
w
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 %� PHONE 22z—'eq
PROPERTY OWNER PHONE
PROPERTY ADDRESS ,
MAILING ADDRESS —
TYPE OF RESIDENCE sing a multiple, mobil home, etc.
TYPE OF BUSINESS _AZ�
BRIEF DESCRIPTION OF HOW THE BUSINESS WILL OPERATE
NUMBER OF PERSONS INVOLVED IN BUSINESS /
LIST NAME OF PERSONS EMPLOYED
• SQUARE FOOTAGE OF USABLE FLOOR AREA
IN HOUSE ( EXCLUDE GARAGE)
� rl
LOCATION AND SQUARE FOOTAGE OF AREA ocr"
OF BUSINESS ACTIVITY IN HOME _
EXAMPLE , "BEDROOM -.125 S.F.") elTiV�/'� 'y,� 1995
C �.
DESCRIPTION OF MACHINERY, EQUIPMENT, AND SUPPLIES BEI USED�IN THE
BUSINESS OPERATION
I HAVE R D,.UNDERSTAND, AND AGREE WITH THE CONDITIONS BY WHICH A
HOME CUPATION P ALLOWED eONDITIONS ATTACHED).
APPLICANT SXGNATURE D TE
IF UPPLICANT IS OTHER THAN PROPERTY OWNER, AUTHORIZATION OF OWNER
OR AGS^;NT IS REQUIRED.
OWNER/AGENT SIGNATURE DATE
lFjsMR``TANT: FALSE OR MISLEADING INFORMATION SHALL BE GROUNDS FOR
DENYING YOUkt HOME OCCUPATION; FAILURE TO COMPLY WITH CONDITIONS
LISTED ON 'TAR' ATTACHED PAGE SHALL BE GROUNDS FOR REVOCATION OF
PERMIT.
• Buildi and-S�fett- Department
APP OVEI: DENIED CONDITIONS ATTACHED
C�
t
78-495 CALLE TAMPICO — LA QUINTA, CALIFORNIA 92253 - (619) 777-7000
1,F ' �' 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 andolic number:
P Y
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
or 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: j% Applicant:
WARNING: Failure to secure workman's compensation c verage 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 OUINTA, CALIFORNIA 92253
�•