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DAVIS (2)m R j— /q' //.- 3 0 f 1111111 II � ��� III IIII IIII � ,, q7incn� uuc D� 1 A Al L P 01 FEE $35.00 CITY OF LA gUINTA 78-495 Calle Tampico, P. O.Box 1504, La Quinta, CA 92253 HOME OCCUPATION PERMIT 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. BUSINESS NAME PHONE r,5 4 PROPERTY OWNER PHONE PROPERTY ADDRESS ' MAILING ADDRESS TYPE OF RESIDENC (single m7tiple, mobil ome, etc.) L/✓C�,v,„ /4tria S3 TYPE OF BUSINESS ; BRIEEIPESCRI,P,TIQN OF HOW'THI BUSINESS WILL OPERATE � Ut I _ NUM9ER-OF PERSONS INVOLVED IN BUSINESS / LIST NAME OF PERSONS EMPLOYED SQUARE FOOTAGE OF USABLE FLOOR AREA IN HOUSE (EXCLUDE GARAGE) 4�0 LOCATION AND SQUARE FOOTAGE OF AREA OF BUSINESS ACTIVITY IN HOME J S S F (EXAMPLE, "BEDROOM -125 S.F.") DESCRIPTION OF MACHINERY, EQUIPMENT, AND SUPPLIES BEING USF.PIN THE BUSINESS OPERATION _1t�//%J u <i,7c,;/�.r �,n ✓-h-,,.,. _ I HAVE D, UNDERSTAND, AND AGREE WITH THE CONDITIONS BY WHICH A HOME �CUtPATIQN �S OWED (CONDITIONS ATTACHED). APPLICANT SIG TURE - 1/ . DATE IF APPLICANT IS OTHER THAN PROPERTY OWNER, AUTHORIZATION OF OWNER IMPORTANT: FALSE OR MISLEADING INFORMATION SIM -,&L BE GROUNDS F©R DENYING YOUR HOME OCCUPATXON• FAILURE TO COMV,�;f 'WITH CONDITIONS LISTED ON THE ATTACH:,, -&D- PAdE SHALL BE GROUNDSs,,F'OR REVOCATION OF PERMIT. _______= � �®e==_____________�__________________ Bu' 1 in aFh�d Safety Do 1.11.rtm,Ra •- r&PPROVED DENIED COND"FTIONS ATTACHED b ' `3 r T4ht 4 4a 78-495 CALLE TAMPICO — LA DUINTA, CALIFORNIA 92253 (619). 777-70k FAX (619) 777-710'. Dear Business Owner: 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. 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 issued. Approval of the Home Owners Association is also required �if you live in a gated community. • If you have any questions, please contact me. Sincerely, Ellie Shepherd Building 5 Safety • buslic.hoc _ MAILING ADDRESS - P.O. BOX 1504 - LA DUINTA; CALIFORNIA 92253 • 0 P 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 ction 0. Date: Applicant: (,-( i 7 �' 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 OUINTA, CALIFORNIA 92253 ���.