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1993 BUSINESS LICENSE APPLICATION FORM
*APPROVED. INITIALSDATE
*DENIED INTIIALS DATE
****************************************************************
......PROOF OF WORKERS COMPENSATION INSURANCE IS REQUIRED........
2" iiiii ilii
80
BUS. LIC. NO.
APPROVED BY BUILDING & SAFETY DEPARTMENT
1.
IS THIS BUSINESS LOCATED
AT YOUR HOME:
YES 09FIZQ, 0"111NO
2.
Business Name: or
( VQ1 \\A
3.
Business Address:
Mailing Address:- 5gAya
5.
Business Phone: ( 61q )
'SM-S03a
6.
Owned By: CORPORATION
PARTNERSHIP
INDIVID
7.
If Corporation or Partnership: Tax I.D.#
8. If Individual Owner: Social Security # 569 -5b-9S61
9. Name of Owner G�obe,�� Cr'me N�afA Title:(r�"'yVQN Z rv'-t�
Or Officers
10. Type of Business:
11. SBE Resale Number: n
12. BUSINESS LOCATED WITHIN THE CITY OF LA QUINTA (Does Not Apply To
Building Contractors):
A. Estimated Gross Business Receipts for New Businesses Only:
B. Previous Year Gross Receipts For Established Businesses:
$
********GOOD ONLY FOR JANUARY 1,1993 THRU DECEMBER 31,1993*******
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 to me and are in full force and effect.
• Signature Title' - Date
Submit Form To:
CITY OF LA QUINTA
BUSINESS LICENSE DIVISION
78-495 Calle Tampico
La Quinta, CA 92253
BUSINESS LOCATED IN THE CITY OF LA QUINTA ONLY
GROSS RECEIPTS
RANGE
CLASS 1
CLASS 2
CLASS 3
0
25,001
- 251-000
- 50,000
$ 15.00
25.00
$ 18.00
3�_._OD�
$ 21.00
36.00
50,001
- 100, 000
30.00
�_�
�3�
43.00
100,001
- 250,000
46.00
55.00
66.00
250,001
- 500,000
76.00
90.00
108.00
500,001
750,001
- 750,000
-
114.00
135.00
162.00
11000,001
1,000,000
- 2,000,000
150.00
400.00
180.00
500.00
216.00
600.00
2,000,001
- 3,000,000
500.00
625.00
750.00
.3,000,001
- 4,000,000
600.00
750.00
900.00
4,000,001
- 5,000,000
700.00
875.00
1,050.00
5,000,001
- 10,000,000
1,000.00
1,250.00
1,500.00
10,000,001
- and up
1,500.00
1,875.00
2,250.00
CLASS Automobile Repair and Services; Laundry, Dry Cleaning &
Garment Services; Manufacturing; Retail & Wholesale
Trade.
CLASS Amusement & Recreation Services, including Motion
Pictures; Architectural Services; Automotive Sales;
Barbers & Hairstylists; Beauty Shops; Engineering
Services; Landscape & Horticultural Services; Operators
Renters & Lessors of Commercial Property; Services to
Buildings; and all other persons engaged in business
not specifically listed elsewhere.
CLASS Accounting, Auditing & Bookkeeping Services; Financial
Services; Insurance Brokers & Services; Legal services;
Management & Public Relations Services; Medical &
Health Services; Real Estate Agents, Brokers, Managers
& Services.
0
•
Titliz 4
78-495 Calle Tampico, La Quinta, CA 92253 (619) 777-7050
FAX (619) 777-7011
Dear Business License Applicant:
every employer who applies for any license or for 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 com Tete and sign a declaration of the 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 workers' compensation insurance carrier and policy number
are:
Carrier
Policy Number
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 workers'
compensation provisions of Section 3700.
Date: A0, -c ? Applicant:
WARNING: FAILURE TO SECURE WORKERS' 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 PRCVIDED FOR IN SECTION 3706 OF THE LABOR
CODE, INTEREST, AND ATTORNEY'S FEES.
MAILING ADDRESS - P.O. BOX 1504 - LA OUINTA, CALIFORNIA 92253