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Taylor (2)11111111111111111111T4tyl 4 78-49S CALLE TAMPICO — LA QUINTA, CALIFORNIA 92253 - (619) 777-7050 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) �lnSlnva f'civ��l�' PROPERTY ADDRESS 5M�Z 8\1&dl \/(Urs- PHONECqLg BUSINESS NAME PROPERTY OWNER -1—v"% • v MAILING ADDRESS (if different from business address) TYPE OF RESIDENCE (single, multiple, mobile home, etc.) TYPE OF OF BUSINESS BRIEF DESCRIPTION OF HOW THE BUSINESS WILL OPERATE C0.iAS L. -5M rnmo-iyx r" vr�f �ISeMPan i- a �� T -RAQa., int UAuc,e A -e u o r k. o v.�- c�v T� NUMBER OF PERSONS INVOLVED -IN BUSINESS l LIST NAMES OF PERSONS EMPLOYED SQUARE FOOTAGE OF USABLE FLOOR AREA IN HOUSE (exclude garage) LOCATION AND SQUARE F OTAGE OF AREA OF BUSINESS ACTIVITY IN HOME (example, "bedroom - 125 sq. Ft.) - 00 sol.;'r • DESCRIPTION OF MACHINERY, EQUIPMENT, AND SUPPLIES BEING U ED IN THE BUSINESS OPERATION - Is ':.:MAILING" "ADDRESS - :P:©:• BOX 1504 - LA QUINTA,. CALIFORNIA 92253 • • I HAVE READ, UNDERSTAND, AND AGREE WITH THE CONDITIONS BY WHICH A HOME OCCUPATION IS ALLOWED (conditions attached). Date l A A Rio Applic is Signature IF APPLICANT IS OTHER THAN PROPERTY OWNER, RENTAL/LEA AGENT IS REQUIRED. Owner/ ent Signature Agent Company. Name AUTHORIZATION OF OWNER OR Date An/ a g/,? L Date 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. SPECIAL CON ATTACHED countera .D.# S---'-7 L 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 777-7054. 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 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: 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. certifythat in the performance of an business activities for which this license is issued, P Y 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 chang in re irements Date: CID Applicant: CLY WARNING: Failure to secure worker's compensation coveragel's 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. lk 0 RECEIPT City of La %uirna,'�8.455a�ia?Ta'mp�co, P: O. Box V1504, La Quints CA 92253 DA �S9 �' .188 -7 RECEIVED FROMS�' I ADDRESS DOLLARS $ �S FOR i it UNT HOW PAID ;7ACXXXW CASH Ey E ORDER dlala�rrrr�rrr rrrrerr r I" tin a* oft *6 ft W&Wft 4* u m mqw 4m w In %a mutt—as—mw.----�) RECEIPT City of La Quinta, 78.495 Calle Tampico, P.O. Box 1504,. La Quinta CA92253 i l 18838 I �' I r DATE. O / 19 RECEIVED ADDRESS FOR ACCOUNT HOW PAID L OFPAID ORDER •,dra'.�Ihs�•�cgiw�IcsriM m.�ars Yl�.tl�r*i1.Mi7beit�:C!'ksYs�+faeko�.'��M.ainpiyla�a.�►�aai�1�`moria.'ar+af�sc.�nmerm•ar.�r'ars®e�c.�roaca�ss RECEIPT City of La Quints, 78=495 Calle Tampico, P.O. Box 1504, La Quinta CA 92253 NATE 9 18889 I RECEIVED FROM { ..J,4+ 4 .'f T' �q #� '1 f r0. 5 Y.fnV� �S f:•,,(�. d W -T' n 0 RECEIPT City of La %uirna,'�8.455a�ia?Ta'mp�co, P: O. Box V1504, La Quints CA 92253 DA �S9 �' .188 -7 RECEIVED FROMS�' I ADDRESS DOLLARS $ �S FOR i it UNT HOW PAID ;7ACXXXW CASH Ey E ORDER dlala�rrrr�rrr rrrrerr r I" tin a* oft *6 ft W&Wft 4* u m mqw 4m w In %a mutt—as—mw.----�) RECEIPT City of La Quinta, 78.495 Calle Tampico, P.O. Box 1504,. La Quinta CA92253 i l 18838 I �' I r DATE. O / 19 RECEIVED ADDRESS FOR ACCOUNT HOW PAID L OFPAID ORDER •,dra'.�Ihs�•�cgiw�IcsriM m.�ars Yl�.tl�r*i1.Mi7beit�:C!'ksYs�+faeko�.'��M.ainpiyla�a.�►�aai�1�`moria.'ar+af�sc.�nmerm•ar.�r'ars®e�c.�roaca�ss RECEIPT City of La Quints, 78=495 Calle Tampico, P.O. Box 1504, La Quinta CA 92253 NATE 9 18889 I RECEIVED FROM { ..J,4+