ANDREASENI IIIIII IIIII'lll IIII � I
50
• FEE $35.00
CITY OF LA QUINTA
78-495 Calle Tampico, P. O.Box 1504, La Quinta,
HOME OCCUPATION PERMIT
CA -9-2253
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 o!Piv�/ez50YA v
PROPERTY OWNER " /%
PROPERTY ADDRESS
MAILING ADDRESS o__,61 ,3c
TYPE OF RESIDENCE (..sin le
TYPE OF BUSINESS
BRIEF DESCRIPTION OF HOW T
PHONE 1,,191 36y
PHONE /,,/7
p1P., mobil home, etc.)
INESS WILL OPERATE
NUMBER OF PERSONS INVOLVED IN BUSINESS �/
LIST NAME OF PERSONS EMPLOYED
• SQUARE FOOTAGE OF USABLE FLOOR AREA
IN HOUSE (EXCLUDE GARAGE) AoV
LOCATION AND SQUARE FOOTAGE OF AREA
OF BUSINESS ACTIVITY IN HOME
(EXAMPLE, "BEDROOM -125 S.F.") /la -9
DESCRIPTION OF MACHINERY,
BUSINESS OPERATION
PMENT, AND SUPPLIES BEING USED IN THE
I HAVE READ, UNDERSTAND, AND. AGREE WITH THE CONDITIONS BY WHICH A
HOME OCCUPATION IS ALLOWED _,CQnITION� ATTACHED) .
1a�- — ���/l e�b�f ,cam,-�–•
CANT SIGNATURE
IF APPLICANT IS OTHER THAN PROPERTY OWNER; AUTHORIZATION OF OWNER
OR AGENT IS REQUIRED.
OWNER/AGENT•SIGNATURE DTE
i N . -IMPORWd!t A:FALSE OR MISLEADING INl'F�"ORNA-fION SHALL -BE GRMWDS FOR
.. S : DBN Z YWk; -5�ME OC,gUPATION; FAILURE +i0 C lPLY WxTH CANi?ITZONS
PERM:`.y 1ISTED O�!t: Ti 3W,'
ATTACHED PAGE SHALL BE GROUNDS FOR FtEVOCATIOPi OF
, .. ..a ... -
.B�til'. ,:.�alE�=►=� __=_�_.`:=�=tea..====_�� �____________________________�:..,.
BU*1d andigafety Department .rith..
APPRGVED DENIED CONDITIONS ATTACHED
•
T4ht 4 4 Qu&M
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 Nu
•Num
Der: h''Yr - 9S .✓� Ivo ;z .'� -96
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.
Date: .71,1�5/94 Applicant: -��-��,/��
WARNING: Failure to secure workman's compensation coverage is
unlawful, and shall subject an employer to criminal penalties and
civic fines up to $100,000. In addition to the cost of
compensation, damages as provided for in Section 3706 of the Labor
Code, interest, and attorney's fees.
bus.fac
MAILING ADDRESS - P.O. BOX 1504 = LA QUINTA, CALIFORNIA 92253 �;�.
•
•
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STATE P.O. BOX 420807, SAN FRANCISCO, CA 94142-0807 JUL O 7
COMPENSATION ft
INSURANCE
FUND .CER_ TIF_ICATE OF WORKERS' COMPENSATION INSURANCE ,",x",=tip t\.t'-V.
JULY 5, •1995 Ksr}�f�r. '_ �Y'ke {b s�. POLICY,NUMBERr95 °:UNIT 0000268
CERTIFICATE EXPIRES. 1 1 9 6
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h.
x irk rfar•x. %�$� rK amt»: ` ;_
>s� r�sF'E ''fr X�• p� ear 4�£�,� k�z r',k s ti'?sa' �,,� 7'>4 X'�'s � '�°�&�''R'� .. �
CITY OF LA QUiNTAka'��s.�
BUILDING AND.nSAFETY
P.O. BOX
a F so? a• &� ?`kid gxi�3 yxr':wx 'a4 - .• �v3 �' �'A. 'ii n5 A.5'"'
.92253
LA QUINTA CA
L
.a 1
This is to certify that we have issued a valid Workers' Compensation insurance policy in a,form approved by the California ''•' '
Insurance Commissioner to the employer named below for the policy period indicated..
This policy Is not subject to cancellation b the Fund exce t upon ten da s' advance written notice to'the employer.•
P Y• 1 Y P P Y
We will also give you TEN days' advance notice should this policy be cancelled prior to its normal expiration_. • . `,'M1, '<P
This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the 2"
policies listed herein. Notwithstanding any requirement,, term, or condition of any contract or other document with
respect to which this -'certificate of insurance may be issued" or, may pertin 'the insurance afforded .by the policies'
described herein'is subject to all the terms excEusions and conditions of such' -p' olicies.`" ". f
x
a:..4
�.,.}X>s''^ rT$° m4 a.. ��3 n:_ b ,# � & 1� s E�. �, _a y°` ,_„m � i PRESIDENT- ..• ^S _
$Y `•w'. 'y
x�� ��• ab.��"P•,4'�'S•,-. 'oo "�; i'° a E sis' �''� �9 t'�3" r� g,.y'x �,2x'w �A ,ams �>4'. ��.' 4 �' ai , '.
EMPLOYER'S LIABILITY LIMIT5INCLUDINGXDE.FENSE COSTS � 1,OOU,000'"PER OCCURRENCE
- a3. � ^m` f.s; ` ' � ..�X•n>. �f�$ a.`>wA ; Z.«•. c�;�s g �`�' A. ' ' ,� �,.,' a. 5;... .� 7 T'>` Ta7_ t .
"�%,e." ¢"rm•.; sK a%.;s✓> '`.:
s
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EMPLOYER:
F—
NORBY P. At
ANDREASEN CONSTRUCTION
P.O. BOX 1681
LA QUINTA CA •92253
RJG
4
BUS. LIC. NO.
1995 BUSINESS LICENSE APPLICATION FORM �.
*APPROVED BY
* DATE
PROOF OF WORKERS COMPENSATION INSURANCE IS REQUIRED PRIOR TO ISSUANCE
1.
IS THIS BUSINESS LOCATED AT YOUR HOME: YES
NO
2.
Business
Name:
3.
Business
Address:yb 4. Mailing
Ad ress wl&w /6W
5.
Business
Phone:
6.
Owned By:
CORPORATION PARTNERSHIP
INDIVIDUAL>
7. If Corporation or Partnership: TAX I.D.# /
8. If Individual Owner: Social Security #
9.
0
10.
Name of Owner
Or Officers
Type of Business:
17 A1 Z;:�FJ'c Title:
11. IF YOU ARE A FOOD VENDOR, DO YOU HAVE A COUNTY REALTH 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 Businesses Only:
s
B. Previous Year Gross Receipts for Established Businesses:
***********GOOD ONLY FOR JANUARY 1,
1995 THRU DECEMBER 31, 1995**********
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 Title0
Send Completed Form.To: 1 /^
CITY OF LA QUINTA.
BUSINESS LICENSE DIVISION
78-495 Calle Tampico
P. 0. Box 1504 4y