Vik• FEE $35.00
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Pjg4I
CITY OF LA QUINTA
78-495 Calle Tampico, P. O.Box 1504, La Qu' -a, 3
HOME OCCUPATION PERMIT, �� OHO
Read each condition listed on the attachment to this foam t see
the proposed activity can comply with the City's Home Occupation
Regulations. Z Z6 1
BUSINESS NAME ,(f-�.actis>>e.�i�c.t.cTn c�
PROPERTY OWNER
PROPERTY ADDRESS
MAILING. ADDRESS O
TYPE OF RESIDENCE (single, multiple, mobi
TYPE OF BUSINESS
BRIEF DESCRIPTION OF HOW THE BUSINESS WIL:
PHONE 6ptQ Sb q
PHONE s
etc.
CC_�-1 0
TE
NUMBER OF PERSONS INVOLVED IN BUSINESS e»
LIST NAME OF PERSONS EMPLOYED
SQUARE FOOTAGE OF USABLE FLOOR AREA
IN HOUSE (EXCLUDE GARAGE) t�e�
LOCATION AND SQUARE FOOTAGE OF AREA
OF BUSINESS ACTIVITY IN HOME am S •�
(EXAMPLE, "BEDROOM -125 S.F.")
DESCRIPTION OF MACHI
BUSINESS OPERATION -
Y, EQUIPMENT, AND SUPPLIES BEING USED IN THE
I R D, UNDERSTAND, AND AGREE WITH THE CONDITIONS BY WHICH A
OCC ATI ( NDITIONS ATTACHED).
PLICANT SIGNATURE DATE
IF APPLICANT IS OTHER THAN PROPERTY OWNER, AUTHORIZATION OF OWNER
OR AGENT ZS E UIRED. y
O ER/A ENT SIGNATURE DATE
IMPORTANT: 'FALSE OR MISLEADING INFORMATION SHALL BE GROUNDS FOR
DENYING YOUR HOME OCCUPATION; FAILURE TO COMPLY,-WITki CONDITIONS
LISTED ON THE ATTACHED PAGE SHALL BE GROUNDS FU!k REVOCATION OF
PERMIT.
a;.
Bui din -and Safety Department
APPROVED DENIED CONDITIONS ATTRCHED
6�q6
f�69
• FEE $35.00
/3
Pjg4I
CITY OF LA QUINTA
78-495 Calle Tampico, P. O.Box 1504, La Qu' -a, 3
HOME OCCUPATION PERMIT, �� OHO
Read each condition listed on the attachment to this foam t see
the proposed activity can comply with the City's Home Occupation
Regulations. Z Z6 1
BUSINESS NAME ,(f-�.actis>>e.�i�c.t.cTn c�
PROPERTY OWNER
PROPERTY ADDRESS
MAILING. ADDRESS O
TYPE OF RESIDENCE (single, multiple, mobi
TYPE OF BUSINESS
BRIEF DESCRIPTION OF HOW THE BUSINESS WIL:
PHONE 6ptQ Sb q
PHONE s
etc.
CC_�-1 0
TE
NUMBER OF PERSONS INVOLVED IN BUSINESS e»
LIST NAME OF PERSONS EMPLOYED
SQUARE FOOTAGE OF USABLE FLOOR AREA
IN HOUSE (EXCLUDE GARAGE) t�e�
LOCATION AND SQUARE FOOTAGE OF AREA
OF BUSINESS ACTIVITY IN HOME am S •�
(EXAMPLE, "BEDROOM -125 S.F.")
DESCRIPTION OF MACHI
BUSINESS OPERATION -
Y, EQUIPMENT, AND SUPPLIES BEING USED IN THE
I R D, UNDERSTAND, AND AGREE WITH THE CONDITIONS BY WHICH A
OCC ATI ( NDITIONS ATTACHED).
PLICANT SIGNATURE DATE
IF APPLICANT IS OTHER THAN PROPERTY OWNER, AUTHORIZATION OF OWNER
OR AGENT ZS E UIRED. y
O ER/A ENT SIGNATURE DATE
IMPORTANT: 'FALSE OR MISLEADING INFORMATION SHALL BE GROUNDS FOR
DENYING YOUR HOME OCCUPATION; FAILURE TO COMPLY,-WITki CONDITIONS
LISTED ON THE ATTACHED PAGE SHALL BE GROUNDS FU!k REVOCATION OF
PERMIT.
a;.
Bui din -and Safety Department
APPROVED DENIED CONDITIONS ATTRCHED
6�q6
T4tit 4
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 a ion 700
Date: Applicant - - - G
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 QUINTA, CALIFORNIA 92253