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GUERRA0 • FEE $35.00 Tavl 4,4 algiam CITY OF LA QUINTA 78-495 Calle Tampico, P. O.Box 1504, La Quinta, A 41 OCT HOME OCCUPATION PERMIT � - 7-,3 199 Read each condition listed on the attachment to this form--to�pation see if the proposed activity can comply with the City's Home Occ Regulations. BUSINESS NAME irEN6P-,A L L V��% PHONE PROPERTY OWNER L A 7,V2A PHONE 7 7 / - © 7.Z 3 PROPERTY ADDRESS S- F/S r A1yt-J E-/2 D)p , L,q ✓!,rliA - 9��5� MAILING ADDRESS S/1/"It AS A,d0//c� TYPE OF RESIDENCE (single, multiple, mobil home, etc.) i'r e TYPE OF BUSINESS G% v D R- D FLi vee Y G BRIEF DESCRIPTION Of HOW TIM BUSINESS WILL OPERATE Pk 6S - M AIAIL21 F POhi "A-LY1e So /`1e-rA-/ Alrg sa c/AL' P_�H jkseor NUMBER OF PERSONS INVOLVED IN BUSINESS S"k-L F LIST NAME OF PERSONS EMPLOYED y`iDo SQUARE FOOTAGE OF USABLE FLOOR AREA IN HOUSE (EXCLUDE GARAGE) ,3o o 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 S v 13 ✓ /p j6A ,U VA ,U -% D- L e-/,9,4 v Ne - I HAVE READ, UNDERSTAND, AND AGREE WITH THE CONDITIONS BY WHICH A BQME OCCUPAT ON ALLOWED eq (CONDITIONS ATTACHED). APPLICANT SIGNATURE DATE IF APPLICANT IS OTHER THAN PROPERTY OWNER, AUTHORIZATION OF OWNER OR AGENT IS REQUIRED.- / [7 - J- e. " lip "10- 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. • Buildi and Safet De artment APPROVED DENIED CONDITIONS ATTACHED Z I • ,. • Tatt q 4a Qu&m BUS. LIC. NO. 1994 BUSINESS LICENSE APPLICATION FORM *APPROVED B * DATE r/��%�Jr� ,r ...... PROOF OF WORKERS COMPENSATION INSURANCE IS REQUIRED....... 1- IS THIS BUSINESS LOCATED AT YOUR HOME: YES_ NO 2 . - Business Name: 3. Business Address: ��S C N 'bP 4. Mailing Address: -L A N i A 4-1 S 2, Z.-3 5. Business Phone:( 7 7 6. Owned By: CORPORATION PARTNERSHIP NDIVIDUAL 7. If Corporation or Partnership: Tax I.D.# 8. If Individual Owner: Social Security 9. Name of Owner G -4IA Title: Or Officers 10. ,we of..,Business: U / C k U 12y- j7FL1 vet 'T 11. IF -YOU ARE A FOOD VENDOR, DO YOU HAVE A COUNTY HEALTH PERMIT:. ,YES NO 12. SBE Resale Number: 13. BUSINESS'LOCATED WITHIN THE CITY OF LA QUINTA (Does Not Apply To Building Contractors): A. Estimated Gross Business Receipts for New Businesses Only: B. Previous Year Gross Receipts For Established Businesses: t ********GOOD ONLY FOR JANUARY 1 1994 THRU DECEMBER 31,1994******* ******* I HEREBY CERTIFY that all the information supplied by me is correct and any licenses required by,the County, State or Federal Government have been issued to me and are in full force and effect. Signature 0 — Title Date Submit Form To: CITY OF LA QUINTA BUSINESS LICENSE DIVISION 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 Section 3700. .. ! 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. i bus.fac MAILING ADDRESS - P.O. BOX 1504 - LA QUINTA, CALIFORNIA 92253 '40(rl