MOORE•
42
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 R0V-!'eU,e✓J AUS PHONE
PROPERTY OWNER CQ sr n1e j,>0vJ',EL PHONE S41KE
PROPERTY ADDRESS ,3'2-ti-,OcS Ale.,,, c, U,111c- C73 2Z
MAILING ADDRESS V90 C5o,4 327- LyN 4?Vi#�,rr ei C -A 9225
TYPE OF RESIDENCE (single, multiple, mobil home, etc.) �;nJ6c.E
TYPE OF BUSINESS D/.57`46crr10,J
BRIEDESCRIPTION OF HOW THE BUSINESS WILL OPERATE
E110,041 Por�7cvs,-• 7V
NUMBER OF PERSONS INVOLVED IN BUSINESS T -CA -3 O
LIST NAME OF PERSONS EMPLOYED �f.S�`Y�/ENi/rG lJ�c'E
SQUARE FOOTAGE OF USABLE FLOOR AREA
IN HOUSE (EXCLUDE GARAGE) /¢S`0
LOCATION AND SQUARE FOOTAGE OF AREA
OF BUSINESS ACTIVITY IN HOME
( EXAMPLE , "BEDROOM -125 S.F.")
�S� ,13/�chtiv
DESCRIPTION OF MACHINERY, EQUIPMENT, ANP SUPPLIES BEING USED IN THE
BUSINESS OPERATION s? 5 `1—FFNa75 �er--topw
I HAVE READ, UNDERSTAND, AND AGREE WITH THE CONDITIONS BY WHICH A
Ii•OME OC TTI�f � A �, ED ,CND/�iL—ATTACHED) .
a �' /%tet (�.
APPLICANT SIGNATURE DATE
IF APPLICANT IS OTHER THAN PROPERTY OWNER, AUTHORIZATION OF OWNER
OR AGENT IS REQUIRED. "UTHIL.:R],
OWNER/AGENT SIGNATURE— DATE
IMPORTANT: FALSE OR MISLEADING INFORMATION SHALL BE GROUNDS FOR
DENYING YOUR HOME OCCUPATION; FAILURE 394� COMPLY WITH CONDITIONS
LISTED ON THE ATTACHED PAGE SHALL BE UNWSI.�FOR REVOCATION OF
PERMIT. 'OR RF,"
ui.l ing and SafetV Department - --= -_-
APPROVED DENIED CONDITIONS ATTACHED
t q q 6 *-NS Al `.
3
91
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 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.
4I certify that in the performance of any business activities
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 su ject to
the worker's compensation provisions of Section 3700.
Date: Applicant :
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 OUINTA, CALIFORNIA 92253 �41�.
BUS. LIC. NO
1996 BUSINESS LICENSE APPLICATION FORM
* APPROVED BY DATE
PROOF OF WORKERS COMPENSATION INSURANCE IS REQUIRED PRIOR TO ISSUANCE
1. IS THIS BUSINESS LOCATED AT YOUR HOME: YES NO
2. Business Name: Pv��'�'e..J G U S
3. Business Address: S'2 �yyJ� A✓P V; I �G— 4. Mailing Address
L.� ou
5. Business Phone: (l0 .S6 S (o(.��
6. Owned By: CORPORATION PARTNERSHIP.
INDIVIDUAL
7. If Corporation or Partnership: TAX I.D. #
8. If Individual Owner: Social Security#
9. Name of Owner
C:�'/SiN� .(>i`�nJ it:L Title:
or Officers
• 10. Type of Business:
'-0 \
-11 - IF .YOU ARE A FOOD VENDOR, DO YOU HAVE A COUNTY HEALTH PERMIT:
YES NO
12. SBEResale Number:
13. BUSINESS LOCATED WITHIN THE CITY OF LA QUINTA (Does Not Apply To Building Contractors):
A. Estimated Gross Business Receipts for New Business Only:
c•> c
$
B. Previous Year Gross Receipts for Established Businesses:
******************GOOD ONLY FOR JANUARY 1, 1996 THRU DECEMBER 31, 1996***************`
I HEREBY CERTIFY that all the information supplied by me is correct and any licenses required by the County, State
or ederal Governmenthavebeen i uuend to me and are in full force and effect.
Signature ' Title Date
Send Completed Form To:
CITY OF LA QUINTA
BUSINESS LICENSE DIVISION
78-495 Calle Tampico
• P.O. Boa 1504
La Quinta, CA 92253