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FEE $35.00
•
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CITY OF LA QUINTA
78-495 Calle Tampico, P. O.Box 1504,
11111111111111111111
31
CQ 6APR 9
6U
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 C i�[ tet-> C rG �-S PHONE
PROPERTY OWNER PHONE
PROPERTY ADDRESS �'Z i �7 l��Pz�/n. At✓C�� r. La
MAILING ADDRESS Srf
TYPE OF RESIDENCE ( ing , multiple, mobil home, etc.)
TYPE OF BUSINESS i5 r -i I VJa
BRIEF DESCRIPTION OF HOW THE BUSINESS WILL OPERATE
e0 gY".":fS
NUMBER OF PERSONS INVOLVED IN•BU�NESS
LIST NAME OF PERSONS EMPLOYED
SQUARE FOOTAGE OF USABLE FLOOR AREA
IN HOUSE ( EXCLUDE GARAGE) Gc�v
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 •F Oky kK/A.QzA, C 414,
I HAVE READ, UNDERSTAND, AND AGREE WITH THE CONDITIONS BY WHICH A
HOME OCCYPATION I?A AI�.gWED (CONDITIONS ATTACHED). i!_
z.�r.• v � . ...�z w[
APPLICANT SIGNATURE
PLICANT IS qTHER THAN PROPERTY OWNER, AUTHORIZATION OF OWNER
ENT IS RE RED.
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.
Building and Safety Department
APPROVED DENIED CONDITIONS ATTACHED
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•
4
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 THE AMOUNT OF COVERAGE AND
EXPIRATION DATE FOR -.WORKMEN'S COMPENSATION IS REOUIRED 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 Se
ption 370.
Date: 4-11y/1 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 OUINTA, CALIFORNIA 92253 �,
Illillllllllllllllll �,�- �����• ��
32
�,-
FEE $ 3
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 C`c°�fiC °�->a �.rG�`I 5 PHONE
PROPERTY OWNERPHONE
PROPERTY ADDRESS (11&6Lou) e,r D f. La.- 0--Z7--
MAILING
MAILING ADDRESS u "
TYPE OF RESIDENCE ( i multiple, mobil home, etc.)
TYPE OF BUSINESS
BRIEF DESCRIPTION OF HOW THE BUSINESS WILL OPERATE�k.
NUMBER OF PERSONS INVOLVED IN-BUSJ.NESS
LIST NAME OF PERSONS EMPLOYED
• SQUARE FOOTAGE OF USABLE FLOOR AREA
IN HOUSE (EXCLUDE GARAGE)�
LOCATION AND SQUARE FOOTAGE OF AREA
OF BUSINESS ACTIVITY IN HOME
( EXAMPLE , "BEDROOM -125 S.. F . ") s� 1 w-
DESCRIPTION OF MACHINERY, EQUIPMENT, AND SUPPLIES BEING USED IN THE
BUSINESS OPERATION ' kKAQnia\t -L3 ,;J,r14,Y
-I HAVE READ, UNDERSTAND, AND AGREE WITH THE CONDITIONS BY WHICH A
HOME OCC ATION I AJWED (CONDITIONS ATTACHED). /A� f'
SIGNATURE
IX—APPLICANT IS R THAN
PROPERTY OWNER,
AUTHORIZATION OF
OWNER
R ENT IS RERED.A2
A
7
S
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.
juil in and SafetyDepartment
•APPROVED DENIED CONDITIONS ATTACHED
�i
`4
BUS LIC N' la
1996 BUSINESS LICENSE APPLICATION FORMy
*APPROVED B.}' DATE
PROOF OF WORKERS COMPENSATION INSURANCE IS REQ1 IRED PRIOR TO ISSUANCE
1. IS THIS BUSINESS LOCATED AT YOUR HOME: YES NO
2. Business Name:'t�t'.��
3. Business Address: { — - 5' {''� T ^�t'4. Mailing Address - S6LV%A-
5. Business Phone:
6. Owned By: CORPORATION PARTNERSHIP INDIViDU
7. If Corporation or Partnership: TAX I.D. #
8. If Individual Owner: Social Security# �� �r+ A
` rT lNg
9. Name of Owner Title:•'V, t
or Officers
• 10. Type of Business:
-11. IF YOU ARE A FOOD VENDOR, DO YOU HAVE A COUNTY HEALTH PERMIT:
YES NO
12. SBEResale Number:
13. BUSINESS LOCATED WITHIN THE CITY OF LA QUINTA (Does Not Apply To Building Contractors):
A. Estimated Gross Business Receipts for New Business Only:
$
B. Previous ear Gross Receipts for Established Businesses:
******************GOOD ONLY FOR JANUARY 1, 1996 THRU DECEMBER 31,1996***************
I HEREBY CERTIFY that all the information supplied by me is correct and any licenses required by the County, State
or Fed al Govenunent have been issued to me and are in full force and effect.
u -t -v. `I��S�o�-vim � .� � % I✓'
Signature Title
Send Completed Foran To:
CITY OF LA QUINTA
BUSINESS LICENSE DIVISION
78-495 Calle Tampico
• P.O. Box 1504
La Quinta, CA 92253