SUAREZ•
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FEE $35.00
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58
CITY OF LA QUINTA
78-495 Calle Tampico, P. O.Box 1504, La Quinta, CA 92253
/o. TO 0 Po
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 1 'ii
PROPERTY OWNER
PROPERTY ADDRESS - A95; Aip.
MAILING ADDRESSo.
TYPE OF RESIDENCE single, ultiple, m
TYPE OF BUSINESS IYpI
BRIFFI SCRIPTION OF HOW THE BUSINESS
P-1 L
NUMBER OPIPERSONS INVOLVED IN BUSINESS
LIST NAME OF PERSONS EMPLOYED
SQUARE FOOTAGE OF USABLE FLOOR AEA
IN HOUSE (EXCLUDE GARAGE)
LOCATION AND SQUARE FOOTAGE OF AREA
OF BUSINESS ACTIVITY IN HOME
(EXAMPLE, "BEDROOM -125 S.F.")
PHONE &M - _�7 (1141
PHONE - I -L
home, etc.)
WILL OPERATE
ID
J OCT 0 3 .199 5
DESCRIPTION OF MACHINERY,QUIPMENT, AND SU�PPLIES BEING
BUSINESS OPERATION Pte\ McQVnA VNG �tft Ot V1e-&4 " .
I HAVE -READ, UNDERSTAND, AND AGREE WITH THE CONDITIONS BY WHICH A
HOME D=UPA';QN.,IS ALLOWED ( CONDITIONS ATTACHED) . _A
IF APPL7PANT�,IS OTHER THAN PROPERTY OWNER,
OR AGENV IS REQUIRED. T
AL®RIZATION 'OF OWNER .'
OWNER/A SIGMA E DATE
.,. NE
IMPORTANT: _ FALSE OR.: MISLE ING INF'ORI TIOeg1= SHALL BE ,.GROUNDS FOR
DENYING YOUR HOME OCCUPATION; FA: ,,'.FRE .T COMPLY WITH CONDI.TIONS
LISTED ON THE ATTACHED PAGE SHALL BE GRObUA' FOR REY: CATION. OF
PERMIT.
Bulling and Safety De�ag:ent
APPROVED DEKLED CONDITIONS ATTACHED
y
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78-495 CALLE TAMPICO — LA QUINTA, CALIFORNIA 92253 - (619) 777-7000
r, 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.
YI-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: I�� Applicant:
WARNING: Failure to secure workman's mpen �OC 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
MAILING ADDRESS - P.O. BOX 1504 - LA OUINTA, CALIFORNIA 92253 ���.