CHARSKARIR' I IIIIII'IIII IIII II'I
04
FEE $35.00
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 >ok ,e
PROPERTY OWNER
PROPERTY ADDRESS -7ri- Q v
MAILING ADDRESS
TYPE OF RESIDENCE LSin
TYPE OF BUSINESS La,,,/or.
BRIEF DESCRIPTION OF HOW
PHONE
PHONE T� � - S"
multiple, mobil home, etc.)
NESS WILL OPERATE
NUMBER Olr PERSONS INVOLVED IN BUSINESS -�
• LIST NAME OF PERSONS EMPLOYED
SQUARE FOOTAGE OF USABLE FLOOR AREA
IN HOUSE ( EXCLUDE GARAGE) S 00 /1Lyp- .�
Q
OFCBUSOINESSDACTZVZTYSQUARE FOINTHOMEOF AREA APS 2 4 1,995
(EXAMPLE, "BEDROOM -125 S.F.")
DESCRIPTION OF MACHINERY, EQUIPMENT, AND SUPPLIES BEING SED IN'_:=
BUSINESS OPERATION �' , C42X=4 . :�&�
I HAVE READ, UNDERSTAND, AND AGREE WITH THE CONDITIONS BY WHICH A
HOME QCCUPAT ON S LLOWED (CONDITIONS ATTACHED)._
APPLICANT SIGNATURE DATE
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 AIFTACHED PAGE SHALL BE GROUNDS FOR REVOCATION IP.
PERMIT.
• lbui in, and Safe�y Department_________________________________---
,POi+`D DENIED CONDITIONS ATTACHED
T4tit 4 4aQw�trw
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 Num
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 s.o 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: �i -GI S pplicant :
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
4
STATE P.O. Box 807, SAN FRANCISCO,CA 94101-0807
W=NOIS
MPENSATION
U R A N C E _
FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
POLICY NUMBER: 290-95 UNIT 0000771
ISSUE DATE: 04-01-95 CERTIFICATE EXPIRES: 04-01-96
CONTRACTORS STATE LICENSE BOARD
P.O. BOX 26000
SACRAMENTO
CA. 95826
SK
JOB: LIC. #563497
INCEPTION DATE: 04-01-93
DIST. OFFICE: RIVERSIDE
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 by the Fund except upon 10 days' advance written notice to the employer.
We will also give you 10 days' advance notice should this policy be cancelled prior to its normal expiration.
This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded
by the 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 pertain, the insurance afforded by the
policies described herein is: subject to allthe terms, exclusions and conditions of such policies.
PRESIDENT
EMPLOYER'S LIABILITY LIMIT.INCLUDING DEFENSE. COSTS: $1,000,000.00 PER OCCURRENCE.
STANDARD EXCLUSION: INDIVIDUAL EMPLOYERS AND HUSBAND AND WIFE EMPLOYERS ARE NOT ELIGIBLE
FOR BENEFITS AS EMPLOYEES UNDER THIS POLICY.
s z;
EMPLOYER
SOUTHWEST LANDSCAPE
LANDSCAPING
79900 HORSESHOE RD
LA QUINTA CA 92253
LEGAL NAME
SKARIN, CHAD A. AND
SKARIN, MARGARET