FISHERI I'llll IIIII'lll II'
4
78-495 CALLE TAMPICO — . LA QUINTA, CALIFORNIA 92253
FAX
APPLICATION FOR
Fee $35-00 HOME OCCUPATION OF A BUSIN
(619) 777-7050
(619) 777-7011
Read each condition listed on the attachment to this form to see if the
complies with the City's Home Occupation Regulations.
APPLICANT .\AMES (List all owners, partners and/or corporation officers)
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PROPERTY ADDRESS
BUSINESS NAME
PROPERTY OWNER deVLI q -
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PHONE 5u q -- 11,5P—
PROPERTY
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MAILING ADDRESS (if different from business address) fV. �• �� l (y Z, z
TYPE OF RESIDENCE (single, multiple, mobile home, etc.)
TYPE OF BUSINESS
BRI
NUMBER OF PERSONS INVOLVED IN BUSINESS
LIST NAMES OF PERSONS EMPLOYED
SQUARE FOOTAGE OF USABLE FLOOR AREA IN HOUSE (exclude garage)
LOCATION AND SQUARE FO TACE OF AREA OF BUSINESS ACTIVITY -2 I TOME (example,
"bedroom - 125 sq:.) ✓ooi,,, 150
• DESCRIPTION. -OF MACHINERYEQUIPMENTEQUIPMENT
OPERATION ��pJ4� �.d LA)AIJo
AND SUPPLIES BEING USE0rIN.`9 HE BUSINESS
MAILING ADDRESS - P.O., BOX 1504 - ' LA Ot;lNTA, CALIFORNIA 92253
i
, I HAVE READ, UNDERSTAND, AND AGREE WITH THE CONDITIONS BY WHICH A HOME
OCCUPATION IS ALLOWED (conditions attached).
• L. G Date 7 113 .0I to
Applicant's Signature
IF APPLICANT IS OTHER THAN PROPERTY OWNER, AUTHORIZATION OF OWNER OR
RENTAL/LEASING GENT IS REQUIRED.
Date —7 1 to
Owner/Ag nt Si ature
3 1 �1
IMPORTANT: FALSE OR MISLEADING INFORMATION SHALL BE GROUNDS FOR DENYING
YOUR HOME OCCUPATION; FAILURE TO COMPLY WITH THE CONDITIONS LISTED ON THE
ATTACHED PAGE SHALL BE GROUNDS FOR REVOCATION OF PERMIT.
/ APP OVED DENIED SPECIAL CONDITIONS ATTACHED
BY: I.D.# �Z
countera
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r` WORKER'S COMPENSATION
• If your company has employees,' a .copy of the workman's compensation policy must accompany the business
license application, indicating dates of coverage and dollar amount. This proof of coverage must be received before
the business license can be processed.
your company has employees, a copy of the workman's
If you do not have employees, please check the last line on the first page: "I certify that ........
If your business is being operated from your home in La Quinta, a Home Occupation Permit is required.before a
business license is used.
If you have any questions, please contact the Code Compliance Division at 777-7050.
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
hereby affirm under penalty of perjury, one of the following declarations:
_ 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 _ 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 SAID POLICY OR CERTIFICATE OF CONSENT SHOWING THE AMOUNT OF
COVERAGE AND EXPIRATION DATE FOR WORKER'S COMPENSATION IS REQUIRED TO
PROCESS THIS APPLICATION.
JK 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, 1 will provide the City with a policy
or certificate copy within ten' (10) days of the change in requirements..
Date: i Z MI&Iri Applicant:
WARNING: Failure to secure worker's compensation coverage is unlawful, and shall subject an
•employer to criminal penalties and civil fines up to $100,000. In addition to the cost of
compensation, damages, interest, and attorney's fees may be assessed to you as provided in
Section 3706 of the Labor Code.