PADDENt FEE $35.00 -
C17Y OF LA, QUINTA o 0..
�
r ..78-495. Ca
lie Tampico, P. O.Box 1504, -'La uinta, CA 9.2253:
a4^ N
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.
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BUSINESS NAME �
`' � �UA PHONE
PROPERTY OWNER ►,r,,� .,p PHONE
PROPERTY ADDRESS 152-196 C K�J�r.►?�A LA
MAILING ADDRESS %, �, ,. �--►
TYPE OF RESIDENCE nqI multiple, mobil home, etc.)
TYPE OF BUSINESS e_5AL9—
BRIEF DESCRIPTION OF HOW THE BUSINESS WILL OPERATEfvi-
NUMBER OF PERSONS INVOLVED IN BUSINESS, t
LIST NAME OF PERSONS EMPLOYED
SQUAME FOOTAGE OF USABLE FLOOR AREA
IN HOUSE ( EXCLUDE GARAGE) aC0 ,,g_
LOCATION AND SQUARE FOOTAGE - OF AREA
Or BUSINESS ACTIVITYINHOLE
( EXAMPLE, "BEDROOM -125 5 S.F.,I) 12�' � ��U L+ g. 6r- .
DESCRIPTION OF MACHINERY, EQUIPMENT, AND SUPPLIES B7E�I'NG'USED IN THE
^� BUSINESS OPERATION �1
I HAVE R" UNDERS:ALLOWED
AND, ANO AGREE WITH 'I`n CONDITIONS BY WHICH AA
HOME OCC A ION IS (CONDITIONS -ATTACHED).
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OPLXCANT SIGNATURE ... _..
IF APPLICANT. IS OTHER THAN PROPERTY OWNER, AUTHORIZATION OF OWNER
OR AGENT I8 REQUIRED.
OWNER/AGENT 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.
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P 'Unc_end Safety DQ'Dartment
APPROVED �DtHIED CONDITIONS ATTACHED
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34
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78-495 CALLE TAMPICO — LA. OUINTA, 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
IRATION DATE.TOR WORKMEN'S COMPEN:
S APPLICATION.
I
P
F.T7117
�1vI 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 wo er's compensation
laws of California, and agree that if I "ioµl become subject to
the worker's compensation provisions of S c io 3700.
Date:- N ;j�- 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
MAILING A00SESS - P.O. BOX 1504 - LA OUINTA, CALIFORNIA 92253 � .