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FEE $35.00
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CITY OF LA QUINTA
78-495 Calle Tampico, P. O.Box 1504, La Quinta,
HOME OCCUPATION'PERMIT
11111111111111111111
77
CA 9 2 3
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 1y)a,-3+efCra4 02,,Yf,-� (S�ky? PHONE lelf -5;0 3/fl0,
PROPERTY OWNER Dati-CIO, A-<-( PHONE
PROPERTY ADDRESS 7g V,; loryA 1) r•
MAILING ADDRESS •S'a mf
TYPE OF RESIDENCE (single, multiple, mobil home, etc.)
TYPE OF BUSINESS C&Ir a, t! r 1fgnir�
BRIEF DESCRIPTION OF H9W THE BUSINESS WILL OPERATE C
A". ' A V, � 1P f av, P /j 1-/ .tom,
NUMBER OF PERSONS INVOLVED IN BUSINESS
LIST NAME OF PERSONS EMPLOYED _ e
SQUARE FOOTAGE OF USABLE FLOOR AREA
IN HOUSE (EXCLUDE GARAGE) 210
LOCATION AND SQUARE FOOTAGE OF AREA
OF BUSINESS ACTIVITY IN HOME
(EXAMPLE, "BEDROOM -125 S.F.")
DESCRIPTION OF MACHINERY, EQUIPMENT, AND SUPPLIES BEING USED IN THE
BUSINESS OPERATION C4 2� / ,d/o„P. / CI�ah►'rn
I HAVE READ/-jJNDERSTANR; AND AGREE -WITH THE CONDITIONS BY WHICH A
HOME OCCUPVIJON IS A14CIWF j,CONDITIONS ATTACHED)
ADPL
TURE
IF APPLICANT IS OTHER THAN PROPERTY OWNER, AUTHORIZATION OF OWNER
OR AGENT IS REQUIRED.
OWNER/AGENT SIGNATURE DATE
IMPPRTANT: FALSE OR MISLEADING INFORMATION SHALL BE GROUNDS FOR
DENYING YOUR HOMES 0CCUPATi10' N;- FAILURE Td --COMPLY WITH CONDITIONS
LI LD ON THE A`1` iCHED PAGE SHALL BE GR�s(MDS FOR REVOCATION OF
PEMT.
Bud: na rind Saf e'tyi D.e�,�oartmeip.*==________________________________
APPROVED„ � �. � -"' DMIED .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
THISS 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 sh ld become subject to
the worker's compensation provisions of S ct on 3700.
Date: % D 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 �;�.
1.
Tay
Q"KA
4 XP BUS. LIC. NO.
1995 BUSINESS LICENSE APPLICATION FORM
TM
*APPROVED BY
DATE
2. Business Name: r'pe-�
3. Business Address:, -78'6 7��l�e r. 4. Mailing Address:
5. Business Phone:
6. Owned By: CORPORATION PARTNERSHIP INDI IDUAL
IS THIS BUSINESS LOCATED AT YOUR
PROOF OF WORKERS COMPENSATION INSURANCE IS REQUIRED PRIOR TO ISSUANCE
HOMEa
: YES. NO
�•� /(pQS��� I,GtY'2
--r
7. If Corporation or Partnership: TAX I.D.#
8. If Individual Owner: Social Security #
9. Name of Owner �+� ����� G�
Title: 1cJo ey'
Or Officers
Type of Business:
IF YOU ARE A FOOD VENDOR, DO YOU HAVE A COUNTY HEALTH PERMIT:
YES NO
SBEResale Number:
r SY-CCS.
BUSINESS LOCATED WITHIN THE CITY OF LA QUINTA (Does Not .Apply To Building
Contractors):
A. `Estimated Gross Business Receipts for New Businesses Only:
B. Previous Year Gross Receipts for Established Businesses: CI��
$ 1
***********GOOD ONLY FOR JANUARY 1, 1995 THRU DECEMBER 31, 1995**********
I HEREBY CERTIFY that all the information supplied by me is correct and any
licens required by the County, State or Federal Government have been issued
to d are �p full �qrc3,,,a
" Signature
nd effect. .0
Title
• Send Completed Form To:
CITY OF LA QUINTA.
BUSINESS LICENSE DIVISION
78-495 Calle Tampico
00,
P. 0. 'Box 1504
La Quinta, CA 92253
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