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• 4a 0 oul MAR 19 1997
78-495 CALLE TAMPICO — LA QUINTA, CALIFORNIA i 922 �"�(Ijjj_7050
FAX (619) 777-7011
APPLICATION FOR
Fee $35.00 HOME OCCUPATION OF A .BUSINESS
Read each condition listed on the attachment to this form to see if the proposed activity
complies with the City's Home Occupation Regulations.
APPLICANT NAMES (List all owners, partners and/or corporation officers)
-F4iarz--H . PaEedes
PROPERTY ADDRESS 52525 AVE. VALLEJO PHONE 564-5657
BUSINESS NAME Paloma Air Conditioning
PROPERTY OWNER Ticnrman u parnrloc
• MAILING ADDRESS if different from business address) P.O. box 3 501
PALM D SRRT CA 92261
TYPE OF RESIDENCE (single, multiple, mobile home, etc.)
TYPE OF BUSINESS Air Condi ioninas s rvi rps
BRIEF DESCRIPTION OF HOW THE BUSINESS WILL OPERATE
buissness account i nom, sc-heeu1 i ng
NUMBER OF' PERSONS INVOLVED IN BUSINESS ? (Hilsband and Wife)
LIST NAMES OF PERSONS EMPLOYED nni,j r, -411assio,martin--calderep
SQUARE FOOTAGE OF USABLE FLOOR AREA IN HOUSE (exclude garage)
LOCATION AND SQUARE FOOTAGE OF AREA OF BUSINESS ACTIVITY IN HOME (example,
"bedroom - 125 sq. Ft.)
. DESCRIPTION OF MACHINERY, EQUIPMENT, AND SUPPLIES BEING USED IN THE BUSINESS
OPERATION ,i/awE , G>mP�rr�n¢y�1g�r»,� ..�� x �i.��►: �..✓C .
MAILING ADDRESS - P.O. BOX 1504 - LA QUINTA, CALIFORNIA 92253
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I HAVE READ, UNDERSTAND, AND AGREE WITH
OCCUPATION IS ALLOWED (conditions attached).
Applicant's Signature
THE CONDITIONS BY WHICH A HOME
Date 3 1
IF APPLICANT IS OTHER THAN PROPERTY OWNER, AUTHORIZATION OF OWNER OR
RENTAL/LEASING AGENT IS REQUIRED.
Date
Owner/Agent Signature
Date
Agent Company Name Agent/Owner Contact Phone #
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.
BUILDING & SAFETY DEPARTMENT/CODE COMPLIANCE DIVISION
APPROVED DENIED ✓ SPECIAL CONDITIONS ATTACHED
BY: I . D. # S DATE
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WORKER'S COMPENSATION
If your company has employees, a copy of the worker'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.
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 Le 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
comglete and sign a declaration that states the following:
WORKER'S COMPENSATION DECLARATION
r1 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 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: STATE COMPENSATION INSURANCE FUND (SCIF )
Policy Number: 132291
9&4; 1 ;7T-L;u 1. 1". K _93 a; 197orm. 1. .. I &� W-1 I a a 11111. 9. Lei
X 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: 3 %1677. 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.
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