LENCHFee $35.00
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78-495 CALLE TAMPICO — LA QUINTA, CALIFORNIA 92253 - (619) 777-7050
FAX (619) 777 -7011 -
APPLICATION FOR PAI®
HOME OCCUPATION OF A BUSINESS
FEB 181997
Read each condition listed on the attachment to this form to see if tr j-KgF i �P�
complies with the City's Home Occupation Regulations.
APPLICANT ,?AMES (List al%'owner -, partners and/or corporation officers)
,Lf . F �1c,/ -° 1/�,yr4 �r�cff
PROPERTY ADDRESS 54-0 50
PHONE -S--64-1,e66.
BUSINESS NAME I4—:016L V160T-bQ651i&Jc
PROPERTY OWNER� 4 / • GE—x,t D i, �,j,4 13. �1 c-4
• MAILING ADDRESS (if different from business address)
6A CSL) W-rA , C.A . C71212--� 3
Po. f3ox 4--,—b
TYPE OF RESIDENCE (single, multiple, mobile home, etc.)
TYPE OF BUSINESS 1�6SIe%►J `�'i T2•'G��'�
BRIEF DESCRIPTION OF HOW THE BUSINESS WILL OPERATE /4AAk:-6 -72icEry6-)r,
. -E D0-4,0 R�dnJs
NUMBER OF PERSONS INVOLVED IN BUSINESS 2'
LIST NAMES OF PERSONS EMPLOYED VAV--Lc.ZF-ebw, -T-0,46 T� Tt�CE
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.) 4-&0fnF7-
SIDESCRIPTION OF MACHINERY, EQUIPMENT, AND SUPPLIES BEING USED IN THE BUSINESS
OPERATION r�..•,R, s J sOgPT1� eQujpAe%�
MAILING ADDRESS - P.O. ROX 1504 - IA ral IINTA, GAI IFnRNIA q??9, ,i 11-i ;
` 1 HAVE READ, UNDERSTAND, AND AGREE WITH THE CONDITIONS BY WHICH A HOME
OCCUPATIWSzALLOWED (conditions attached).
lJv`� vb�7JM
A/TALALEASING
' Signature 4.
IFCANT IS OTHI
R AG
Owner/Agent Signature
Agent Company Name
Date 2' /7' y 7
q
THAN PROPERTY OWNER, AUTHORIZATION OF OWNER OR
IS REQUIRED.
` Date
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.
• � R ED DENIED SPECIAL CONDITIO S ATTACHED
BY:X::�a I . D. # �� DATE �f ��
•
countera
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
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: 5/A- T-6 T � ---- �G-i c_Y e-,) F- rl-&g LJ /79 GeT
Policy Number: 7 u u iT- o -6-o1 ( ,7
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.
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 J sou become subject to the
worker's compensation provisions of Section 3700, 1 wil r vide the City with olicy
or certificate copy within ten (10) days of the ch7nge i quirents.
Date: 2 " �' Applicant:
WARNING: Failure to secure worker's compensation cov age is unlawful, an shall subject an
• employer to criminal penalties and civil fines up to 100,000. In addIon 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:
1�
NATE
COMPENSATION
INSUR^NOE
0 FUND
-M
-WA
Qu"ii
CITY (INF LA
'E'NT. A
ATTR: BUILs .1 GbiepriR Al
.R AP�
P 0 B()X 1504
LA QUINTA CA. 9V.5
L
This is to certify that we have issued a valid Workers' Compensation insurance policy in'a -form approved by the California
Insurance Commissioner jo the employer named below for the policy period indicated.
This policy is not subject to cancellation by the, Fund.ex�cept upon ten days' advance .written notice to.the employer.
We will also give you TEN days' advance notice should this policy be cancelled pri'orto its'normal expiration.
This certificate of insurance is not an insurance 'policy and does.not amend, extend'or alter the coverage afforded by the
policies listed herein.* Notwithstanding any requirement,.. term; I or condition of., any contract or other document with
'S'6681'pr. may,'p�rtain,-.,I
respect to which ;,this 1 -%certificate ot.AhiUrance may ie�AS"the insurance :1 afforded by the policies
described herein,.i§:,.§0bj6ct to all the terms, exclusions ancon I iont-of such ,*5' policies -i" ''r
po"" ,!
Ip
Ift, �e":
•7 A.
,AUTHORIZED REPRESENTATIVE
.000 RE
EMPLOYER'S
6 00(ols,000 RE
J.
Ov
EMPLOYERS PLOY
F
LEENDEL VE14'ru
RO BOX 456
..................
LA-QUINTA CIA' 92253:.NRI