VALENCIAi fi>t44,�I%LrL1 iiV
FEE $35.0014
III'I'llllllllllllll
CITY OF LA QUINTA
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 \) UA -L 6!1-jg2..Z3 PHONE 17460 -1502-
PROPERTY OWNER -DUBAt-c'-w 14 PHONE
PROPERTY ADDRESS y-1$ n 1 A-pics W-1*
MAILING ADDRESS 6ttftc
TYPE OF RESIDENCE (single, multiple, mobil home, etc.) �-
TYPE OF BUSINESS Pati iWWWr
BRIEF DESCRIPTION OF HOW THE BUSINESS WILL OPERATE
t:> . -. n.. .. -
NUMBER OF PERSONS INVOLVED IN BUSINESS
LIST - NAME OF PERSONS EMPLOYED „P'
SQUARE FOOTAGE OF USABLE FLOOR AREA
IN HOUSE ( EXCLUDE GARAGE.) I bI1 JF.
. LOCATION AND SQUARE FOOTAGE OF AREA
OF BUSINESS ACTIVITY IN HOME
(EXAMPLE, "BEDROOM -125 S.F.")
DESCRIPTION OF MACHINERY, EQUIPMENT, AND SUPPLIES BEING USED IN THE
BUSINESS OPERATION ComP-
I HAVE READ DERSTAND, AND AGREE WITH THE CONDITIONS BY WHICH A
HOME OCCUPA -N IS ALLOWED (CONDITIONS ATTACHED).
-�.. '5,5,W.
APPLICANT SIGNATURE nATF_
IF APPLICANT IS OTHER THAN PROPERTY OWNER, AUTHORIZATION OF OWNER
OR AGENT IS 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.
--------------------
Buil;'inq and Safety Department
APPROVED DENIED CONDITIONS ATTACHED
c lo-vo
6'Jz
0
0
i
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 fora 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 wooer's compensation
laws of California, and agree that if I sho ecome subject to
the worker's compensation provisions of Sect 'o 700.
Date:
7 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 ADDRESS P.O. BOX 1504 - LA QUINTA, CALIFORNIA 92253 �.