VILLEGAS1111111 IIIII IIII IIII /�� e 9 -22 �Y
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 PHO
PROPERTY OWNER L PHONE
PROPERTY ADDRESS
MAILING ADDRESS
TYPE OF RESIDENCE ngle multi le mobil home, etc.)
TYPE OF BUSINESS
BIEF DES BIPTION F OW THE BUSINES7 WILL OPERATE
NUMBER OF PERSONS INVOLVED IN BUSINESS
LIST NAME OF PERSONS EMPLOYED / r 7rLj
SQUARE FOOTAGE OF USABLE FLOOR A A
IN HOUSE (EXCLUDE GARAGE)/&J,
LOCATION AND SQUARE FOOTAGE OF AREA
OF BUSINESS ACTIVITY IN HOME
(EXAMPLE, "BEDROOM -125 S.F.")
DESCRIPTION OF MACHIRY, EQUIPMENT, AND SUPPLIES BEING USED IN THE
BUSINESS OPERATIONT7 /�
I HA EAD UNDERSTAND, AN AGREE WITH THE CONDITIONS BY WHICH A
HOM CUP ION I AL D DITIONS ATTACHED).
APPLICA%NT S I GNATUjCrE 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.
•Building and Safety Department
APPROVED DENIED CONDITIONS ATTACHE
sy
1.
2.
at RUM&
BUS. LIC. NO.
1994 BUSINESS LICENSE APPLICATION FORM
************** ** ** ****
*APPROVED BY
* DATE
......PROOF OF WORKERS COMPENSATION INSURANCE IS REQUIRED........
IS THIS BUSINESS LOCATED AT YOUR HOME: YES
NO
Business Name:
3. Business Address: 4. Mailing Address:
Jt-o� �� �{-�iU�t�� �cli� �� � QUir�� �• l!Z?5�
5. Business Phone:( -6z
6. Owned By: CORPORATION PARTNERSHIP INDIVIDUAL
7. If Corporation or Partnership: Tax I.D.#
8. If Individual Owner: #_
9. Name of Owner / j,/ /(�f ��G -zo Title • 1WX1-71
Or Officers
• 10. Type of Business: Tjp.J
,
�1. IF.YOU ARE A FOOD VENDOR, DO YOU HAVE A COUNTY HEALTH PERMIT:��� .
YES NO
12. SBE Resale Number:
f
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 1,1994 THRU DECEMBER 31,1994*******
I HEREBY CERTIFY that all the information supplied by; me is correct and
any 1' enses required by the County, State or Federal Government have been
iss d to a and are i u force and effect.
`v�- • / Signature A/Z/
Title
Date
Submit Form To:
CITY OF LA QUINTA
BUSINESS LICENSE DIVISION
78-495 Calle Tampico
La Quinta, CA 92251
78-495 CALLE TAMPICO — LA OUINTA, 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'DEC.LARATION
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:
L�
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 t worker's compensation
laws of California, and agree that if sh uld become su j ct to
the worker's mpen ation provisions o S U on 370 .
Date: l�/
Applicant: /
PP
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: f ac
MAILING ADDRESS - P.O. BOX 1504 LA OUINTA, CALIFORNIA 92253 �.