Wrankle• FEE $35.00
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CITY OF LA QUINTA
78-495 Calle Tampico, P. O.Box 1504, La Quinta,
HOME OCCUPATION PERMIT
18
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CA 9�225�3_
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JAN 05 1995
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Read each condition listed on the attachment to this form t"o-s.ee._ief_
the proposed activity can comply with the City's Home Occupation
Regulations.
BUSINESS NAME "ONE 3` -ES —UZ
PROPERTY OWNER pVi HONE
PROPERTY ADDRESS ZS'
MAILING ADDRESS
TYPE OF RESIDENCE (single, multiple,'mobil home, etc.)
TYPE OF BUSINESS <
BRIEF DESCRIPTION GV HOW THE B INESS' WILL.OPERATE
NUMBER OF PERSONS INVOLVED IN BUSINESS \) S AF
LIST NAME OF PERSONS EMPLOYED
• SQUARE FOOTAGE OF USABLE FLOOR AREA
IN HOUSE (EXCLUDE GARAGE) 2(a��- S
LOCATION AND SQUARE FOOTAGE OF AREA
OF BUSINESS ACTIVITY IN HOME S \:��I (��- S C -
(EXAMPLE, "BEDROOM -125 S.F.") `
►std b
DESCRIPTION OF MACHINERY, EQUIPMENT, AND SUPPLIES BEING USED IN THE
BUSINESS OPERATION [ r.vc�2S IfeM CcS %zNe*A CoA
I
I HAVE PARD, UNDERSTAND AGREE WITH THE CONDITIONS BY WHICH A
HOME OC ATION/IS A WED (CONDITIONS ATTACHED). A
APPLICANT SI
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.
• Bui no.and Safety Department
APPROVED DENIED CONDITIONS ATTACHED
SY
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T4ht 4 4e& Qumm
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 wor is comp sation
laws of California, and agree.that if I shoul /becopie s ject to
the worker's compensation provisions of Sect'
Date: — % 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
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MAILING ADDRESS - P.O. BOX 1504 - LA OUINTA, CALIFORNIA 92253 ��
1.
2.
3.
5.
6.
4 BUS. LIC. NO.
1995 BUSINESS LICENSE APPLICATION FORM
******************* ********
*APPROVED BY
* DATE
*********************** ****
PROOF OF WORKERS COMPENSATION INSURANCE IS REQUIRED PRIOR TO ISSUANCE
IS THIS BUSINESS LOCATED AT YOUR HOME: YES NO
Business Name: C CJOS Ic�,cK-,,F,%
Business Address : 4� / ems" �,c 4 Mailing Address:
Business Phone:-
Owned By: CORPORATION PARTNERSHIP INDIVIDUAL
7. If Corporation or Partnership: TAX I.D.#
8. If Individual Owner: Social Security #
9. Name of Owner Title:_��,,�
Or Officers CW 9A4JkL �,
• 10. Type of Business:
11. IF YOU ARE A FOOD VENDOR, DO
YES
rig
HAVE A COUNTY HEALTH PERMIT:
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:
$ 2 Nr -,n
B. Previous Year Gross Receipts for Established Businesses:
***********GOOD ONLY FOR JANUARY 1, 1995 THRU DECEMBER 31, 1995**********
I HEREBY CERTIFY that al the information supplied by me is correct and any
licenses r ire jyt unty, State or Federal Government have been issued
-to me and a e i fa and effect.
Sig atu-re Title Date
• Send Completed Form To:
CITY OF LA QUINTA.
BUSINESS LICENSE DIVISION
78-495 Calle Tampico
P. 0. Box 1504
La Quinta, CA 92253