BROCK• FEE $35.00
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CITY OF LA QUINTA 42
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 OUi� PHONE (Mg)3W.jj(
PROPERTY OWNER PHONE
PROPERTY ADDRESS
MAILING ADDRESS I.
TYPE OF RESIDENCEWk STYPE OF BUSINES
BRIEF DESCRIPTION OF
tiple, `feobil home, etc.)
HOW THE BUSINESS WILL OPERATE
IVVn ki fns n.n Li -!r r/'AJ'I/n
NUMBER OF PERSONS INVOLVED IN B S NESS
LIST NAME OF PERSONS EMPLOYED�� G
. SQUARE FOOTAGE OF USABLE FLOOR AREA
IN HOUSE ( EXCLUDE GARAGE) (IUD l V V
LOCATION AND SQUARE FOOTAGE OF AREA MGVJDn Y VI Q qiqj ,
OF BUSINESS ACTIVITY IN HOME �l
( EXAMPLE , "BEDROOM -12 5 S.F.") WOO K r fr C2
f .
DESCRIPTION OF MACH NERY, EQUIPMENT, AND SUPPLIES HEI G USE N THE
BUSINESS OPERATION WW tudlA,r
I HAVE' R;A;OWED
TD, AND AGREE WITH THE CONDITIONS BY WHICH A
HOME 0 (CONDITIONS ATTACHED).2 Q
PLI G ATURE DATE
IF APPtICA16 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;..FAILLYRE TO COMPLY WITH CONDITIONS
LISTED ON THE . ATTACHED PAGE "SHALL'' a, - ...GROUNDS FOR REVOCATION OF
]HERMIT.
^- _
BU12d4nq and Safety De aPtin4ait
APPROVED-- DENIED _ CONDITIONS ATTACHED
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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 become subject to
the worker's compensation provisions of 700.
Date: � Af Applicant:
WARNING: Failure to secure workman's pensation 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 ���.