Arnold & BroylesFEE $35.00
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CITY OF LA QUINTA
11111111111111111111
8-495 Calle Tampico, P. O.Box 1504, La Quinta, CA 92253
HOME OCCUPATION PERMIT V /<\ �r
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.
30()'t�BUSINESS NAME / wo1-05 LM�OSGgQ�K'1l��w�►��.cePHONE 3 _ - 5349
PROPERTY OWNER PHONE(.- 4
PROPERTY ADDRESS C� —
MAILING ADDRESS
TYPE OF RESIDENC sin le, multiple, mobil home, etc.)
TYPE OF BUSINESS L�/�SC,Al/C �/!/NTE/vpil/f-2
BRIEF DESCRIPTION OF HOW THE BUSINESS WILL OPERATE
NUMBER OF PERSONS INVOLVED IN BUSINESS
LIST NAME OF PERSONS EMPLOYED , n6oY1 �r- old
• SQUARE FOOTAGE OF USABLE FLOOR AREA
IN HOUSE ( EXCLUDE GARAGE)
11300
LOCATION AND SQUARE FOOTAGE OF AREA
OF BUSINESS ACTIVITY IN HOME
( EXAMPLE , "BEDROOM -125 S.F.") &nW5
DESCRIPTION OF MACHINERY, EQUIPMENT, AND SUPPLIES BEING USED IN THE
BUSINESS OPERATION LA�✓ni fti.(ok>P.✓ i�2eGQ wiu /✓ h'0�12.1�� /-l�yy✓ ?'boC�
I HAVE READ, UNDERSTAND, AND AGREE WITH THE CONDITIONS BY WHICH A
H� OCCUPATION ZSR/ ALLO�JT D ( CONDITIONS ATTACHED) . 10
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ICANT SIGNATURE DATE
IF APPLICANT IS OTHER THAN PROPERTY OWNER, AUTHORIZATION OF OWNER
OR AGENT IS REQUIRED. K t/
K--: rD / 3
61 OWNER/A ENT 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.
• Hui=d=n========fet=====artment__________________________________
ROVED 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 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.
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.
e -
Date: _ce
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
140�,
MAILING ADDRESS P.O. BOX 1504 - LA QUINTA, CALIFORNIA 92253 ���.