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JAN 2 4 1995
• FEE $35.00 IBY / 7 S
CITY OF LA QUINTA�5�
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
PROPERTY OWNER
PROPERTY ADDRESS
MAILING ADDRESS
TYPE OF RESIDENCEIS
TYPE OF BUSINESS
BRIEF DESCRIPTION OF
MINl IL. PHONE I[31jfr
�MXIPHONE
multiple, mobiT��, etc.)
HOW THE USINESS WILL OPERATE
NUMBE F PER NS INVOLVED IN BUSIN SS
LIST NAME OF PERSONS EMPLOYED N l
SQUARE FOOTAGE OF USABLE FLOOR ARE
• IN HOUSE (EXCLUDE GARAGE)
LOCATION AND SQUARE FOOTAGE OF A EA
OF BUSINESS ACTIVITY IN HOME N' p
(EXAMPLE, "BEDRRO M_ 12 5 S.F.")
Dix U
DESCRIPTION OF MACHI ERY, EQUIPMENT, AND SUPPLIES BEING USED IN THE
BUSINESS OPERATION ,oM2ij -ft- rs
IVE READ, UNDERSTAND, AND AGREE WITH THE CONDITIONS BY WHICH A
H E'jCUTI S ALLOWED (CONDITIONS ATTACHED).
APPLICANT SIQ4ATURE 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.
• ;Build nq and Safety Department
lffN APPROVED DENIED CONDITIONS ATTACHED
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78-495 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 fora 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 activ.ities.conducted for which this
license is issued.
c/ 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.
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 o Sec ion 3700..
Date : -- - l Applicant:ILP 11
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 QUINTA, CALIFORNIA 92253
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1995 BUSINESS LICENSE APPLICA
* DATE
**************** * ** ****
12. SBEResale� Number:
13. BUSINESS LOCATED ;WITHIN'THE`ICITY"OF LA!WI•NTA (Does Not .Apply To Building
Contractors)
A. Estimat diiGross;=BusinessqReceiptskf6raNevi;Businesses Only•
B. Previous-;Year;;Gross� Recdipts: fortEstabl:ished Businesses:
***********GOOD.,ONLY FORrjJANUARY1. 19.95.. THRUjDECEMBER' 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
torte a&,d are in full force and effect.
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Signature
0
•rizie
Send Completed Form.To:
CITY OF LA QUINTA
BUSINESS LICENSE DIVISION
78-495 Calle Tampico
P. 0. Box 1504
La Quinta, CA 92253
�t
1.
IS THIS BUSINESS LOCATED:AT
YOUR HOME: YES ✓ NO
2.
Business Name: \�i�IA l•r,�,r
IT Z tC'`d
3.
Business
18502 4 . "Mailing Address:- 5gM9,
LA IL I N
o
�..•,,r r
5.
Business Phone:
y
6.
Owned By: '' CORPORATION.
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PARTNERSHIP INDIVIDUAL•
7.
If Corporation -or Partnersh
``•.cTAX I.D.# ,;44rr
8.
If Individual Owner: Social
Security # 2`�
9.
Name of Ownery�.,- ��,
, `�" Z, Title:
Or Officers
Type of Business:
.
11.
IF YOU ARE A FOOD --=VENDOR, - DO
-YOU44AVE. °A`FCOUNTY- HEALTH PERMIT:
YES
NO
12. SBEResale� Number:
13. BUSINESS LOCATED ;WITHIN'THE`ICITY"OF LA!WI•NTA (Does Not .Apply To Building
Contractors)
A. Estimat diiGross;=BusinessqReceiptskf6raNevi;Businesses Only•
B. Previous-;Year;;Gross� Recdipts: fortEstabl:ished Businesses:
***********GOOD.,ONLY FORrjJANUARY1. 19.95.. THRUjDECEMBER' 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
torte a&,d are in full force and effect.
ra"
Signature
0
•rizie
Send Completed Form.To:
CITY OF LA QUINTA
BUSINESS LICENSE DIVISION
78-495 Calle Tampico
P. 0. Box 1504
La Quinta, CA 92253
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