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CITY OF LA QUINTA 39
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 0-0127 's . � -t PHONE s"G 7-.31 7 2 -
PROPERTY
PROPERTY OWNER (- u/17-,� ss PHONE
PROPERTY ADDRESS 79910 Lll 00,9Z1n4 1,4 Qy-�Alr4 CA 9Zas•' 3
MAILING ADDRESS '78 GA P9GMr-) 6 A U,,^1 4 z z s- 3
TYPE OF RESIDENCEsingle' multiple, mobil home, etc.)
TYPE OF BUSINESS 7.9-K �i�F����T�d.✓
BRIEF DESCRIPTION OF HOW THE BUSINESS WILL OPERATE
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NUMBER OF PERSONS INVOLVED IN BUSINESS /
LIST NAME OF PERSONS EMPLOYED L'u?Tits f'�/1•ey
SQUARE FOOTAGE OF USABLE FLOOR AREA
IN HOUSE ( EXCLUDE GARAGE) /"/70 sQ.,Cr
LOCATION AND SQUARE FOOTAGE OF AREA
OF BUSINESS ACTIVITY IN HOME ov✓41
(EXAMPLE, "BEDROOM -125 S.F.")
DESCRIPTION OF MACHINERY, EQUIPMENT, AND SUPPLIES BEING USED IN THE
BUSINESS OPERATION 6,01Mf u i E/1, M s6 /J2i•�T�2
I HAVE READ, UNDERSTAND, AND AGREE WITH THE CONDITIONS BY WHICH A
HOME OCCUPATIPN IS A.I OWED (CONDITIONS ATTACHED) .
APPLICANT SIGNAT
IF APPLICANT IS ,OTHER
OR AGENT IS REQUIRED.
THAN PROPERTY OWNER:;''
DATE
AUTIfORIZ i IOiC 6F OWNER
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OWNER/ AdE . t. SI"ATURE tom. �'�D� T
IMPOR, T: FALSE' OR--MZ�LEADII�itn-..'.'I'NFORMATION SHALI;t;; Bip .'d dtJ bS FOR
DENYING Y0 HOME -OCCUPATION; '�'AILURt TO. -'COMPLY. W17M .•CONDITIONS
T H£;D PAGE SHALL HE "GY,=X t Sa *-,FOiZ ii: $ ATZON OF
LIS T£f .0[=
PERMIT.
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d. Saf DENIED CONDITIONS ATT aED-`' ..
APPROVE.
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78-495 CALLE TAMPICO — LA DUINTA, 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 3710.1 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.
Date: Z zO— 5?6 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 DUINTA, CALIFORNIA 92253 ���.
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78-495 CALLE TAMPICO — 'LA QUINTA, CALIFORNIA 92253 - (619) 777-7000
FAX (619) 777-7101
Dear Business Owner:
If your company has employees, a copy of the workman's
compensation policy must accompany the business license
application, indicating dates of coverage and dollar amount.
This proof -of coverage must be received before the business
license can be processed.
If you do not have employees, please check the last line on the
first page: "I certify that...."
If your business is being operated from your home in La Quinta, a
Home Occupation Permit is required before a business license is
issued. Approval of the Home Owners -Association is also required
i f .you live in- a gated community.
If you have any questions, please contact me.
Sincerely,
Ellie Shepherd
Building & Safety
buslic.hoc
MAILING ADDRESS - P.O. BOX 1504 - LA OUINTA, CALIFORNIA 92253