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76
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 L , J, 61,<o -y �'Or✓ST/2 PHONE -?6 &
PROPERTY OWNER Zoll& 73DA,,j 0150;,,J PHONE
PROPERTY ADDRESS --)0-765 Lode- D2
MAILING ADDRESS �* 78--765 10 114 114QuirQ.g ,64 82757
TYPE OF RESIDENCE (single, multiple, mbbil home,"etc.
TYPE OF BUSINESS (01je 14 e'07vVgC7-0r2 _
BRIEF DESCRIPTION OF HOW THE BUSINESS WILL OPERATE _
NUMBER OF PERSONS INVOLVED IN BUSINESS
LIST NAME OF PERSONS EMPLOYED ),,*YLc vG;
• SQUARE FOOTAGE OF USABLE FLOOR AREA
IN HOUSE (EXCLUDE GARAGE) _21YO
LOCATION AND SQUARE FOOTAGE OF AREA
OF BUSINESS ACTIVITY IN HOME
( EXAMPLE , "BEDROOM -125 S.F.") OrFler 115 S_ F
DESCRIPTION OF MACHINERY, EQUIPMENT, AND SUPPLIES BEING USED IN THE
BUSINESS OPERATION -5?1 )re<
I HAVE -READ, UNDERSTAND, AND AGREE WITH THE CONDITIONS BY WHICH A
HOME QCCUPATION IS ALLOWED (CONDITIONS ATTACHED). _
LIC--IUM-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 ATTACHED PAGE SHALL BE GROUNDS FOR REVOCATION OF
PERMIT.
• ui1====-aDepartment
__________________________________
APPROVED DENIED CONDITIONS ATTACHED .100
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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.
V 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:
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 OUINTA, CALIFORNIA 92253 ���.
A lw( Ii I I . 4r `0011/
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1995 BUSINESS LICENSE APPLICATION FORM
Send Completed Form To:
CITY OF LA QUINTA
BUSINESS LICENSE DIVISION
78-495 Calle Tampico
P. 0. Box 1504
La Quinta, CA 92253
1. Business Name:
0
BUS. LIC. NO.
go VI
APPROVED BY
DATE
AA zZ TE
2. Business Address: ov"P iU h� 1
2 0-53
3. Mailing Address: �y
L
4. Business Phone: ( /9 ) 360 -76 K/
5. Owned By: CORPORATION PARTNERSHIP IVIDUAL
Ii Corporation or Partnership: TAX I.D.i
7. If Individual Owner: Social Security i S 7?- 0.2 -7920
S. Name of Owner or Officers and Title: /_011%5 �H� OLSdw
9. SBEResale Number:
10.
Number of Decals Needed: ,�
j., `�
11.
CONTRACTORS ONLY:
A. Type of Contractor:
ive,�
B. Classification:
C. State License Number:
3 2,29,05
A
or B License Classification
$100. Per Year or
esti-Annum].
C
License Classification -
$ 50.00 Per Year or $25.
-Annual
CONTRACTORS ARE ON A CALENDAR YEAR BASIS ONLY; ANNUAL FROK JANUARY 1ST THROUGH
DECEMBER 31ST. SEMI-ANNUAL FROM JANUARY 1ST THROUGH JUNE 30TH; OR JULY 1ST
THROUGH DECEMBER 31ST.
• 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.
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