Bass,: tr- I IIIIII VIII IIII IIII01
FEE $35.00
CITY OF LA QUINTA
71ti1
Calle Tampico, P. O.Box 1504, La Quinta, CA
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 �� PHONE 6l4 St/=o
PROPERTY OWNER SS/ PHONE JF6K ff60
PROPERTY ADDRESS (9-047T AeA.Ag U
MAILING ADDRESS
TYPE OF RESIDENCE (single, multiple, mobil home, etc.)
TYPE OF BUSINESS
BRIEF DESCRIPTION OF HOW THE BUSINESS WILL OPERATE A/E73 b- /L
J•&I'vj� E
NUMBER OF PERSONS INVOLVED IN BUSINESS
LIST NAME OF PERSONS EMPLOYED -7;Vn1A5 Rj:5S TA.�'1'9 9zd
• SQUARE FOOTAGE OF USABLE FLOOR AREA
IN HOUSE (EXCLUDE GARAGE)
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 P16<6110
I HAVE READ, UNDERSTAND, AND AGREE WITH THE CONDITIONS BY WHICH A
HOME CUPATIO IS AGLOW D ONDITIONS ATTACHED). i
APPLICANT SIGNATURE DATE
IF APPLICANT IS OTHER THAN OPERTY OWNER, AUTHORIZATION OF OWNER
OR AGE REQU R
IMPORT4NT:, . FALSE OR MISI:EADING INFORMATION SHALL BE GROUNDS FOR
DENYING.o :YHOt, OCCUPATION.; FAILURE TO COMPLY WITH CONDITIONS
LISTED ONS ATTACHED PAGE SHALL BE -GROUNDS FOR REVOCATION OF
,
. jsi
PERMI ". „
•BuilAing and Safety. Deartment "
PROVED DENIED CONDITIONS ATTACHED
�7
T4t�t 4 4a QuiRm
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.
Ju
I have and will maintain worker's compensation insurance, as
'red by Section 3700 for the duration of any business
vities 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:
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
*4,
MAILING ADDRESS - P.O. BOX 1504 - LA OUINTA, CALIFORNIA 92253 ;(;
•
BUS. LIC. NO.,
1995 BUSINESS LICENSE APPLICATION FORM
Send Completed Form To:
CITY OF LA QUINTA ******************
BUSINESS LICENSE DIVISION *APPROVED BY
78-495 Calle Tampico * DATE
P. 0. Box 1504-
La
504 La Quinta, CA 92253 ************** ** ***
1.
2.
PROOF OF WORKERS COMPENSATION INSURANCE
Business Name: Z-
•2. Business Address:
IS REQUIRED
PRIOR TO ISSUANCE
3.
Mailing Address: �
/ /Govz
4.
Business Phone:
5.
Owned By: CORPORATION
PARTNERSHIP
ilkIVIDUAL.
If Corporation or Partnership: TAX
I.D.#
7.
If Individual Owner: Social Security #
04 Z-71 7,%
8.
Name of Owner or Officers and Title:
9.
SBEResale Number:
10. Number of Decals Needed:
11 . CONTRACTORS ONLY: COPS[ OF STATS CONTRACTORS LICSNss POCICBT
A.
B.
C.
Type of Contractor:_
Classification:
State License Number:
A or B License Classification Per Year or $50.00 Semi -Annual
C License Classification $ 50.00 Per Year or $25.00 Semi -Annual
CONTRACTORS ARE ON A CALENDAR YEAR BASIS ONLY; ANNUAL FROM JANUARY 1ST THROUGH
DECEMBER 31ST. SEMI-ANNUAL FROM JANUARY 1ST THROUGH JUNE 30TH; OR JULY 1ST
THROUGH DECEMBER 31ST.
.EREBY 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.
Signature
Title
J f 'jo. J .
Date
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
.............................. ...........................................................................................
.......;......................................................................................................................................;
COTYPE OF INSURANCE POLICY NUMBER' : POLICY EFFECTIVE POLICY EXPIRATION LIMITS
LTR: DATE (MM/DD/YY) DATE (MM/DD/YY)
. ..... .. .....
.....................................................................................................................................:...............................
GENERAL LIABILITY PENDING 07/18/95 07/18/96 GENERAL AGGREGATE $
1000000
A.........,:................................................................................
X COMMERCIAL GENERAL LIABILITY PRODUCTS-COMP/OP AGG. $
: ......................... ................1000000
1000000
.......... .............................................
.. ADV. INJURY ...............
CLAIMS MADE X ;OCCUR. $
OWNER'S 8 CONTRACTOR'S PROT. EACH OCCURRENCE $
1000000
.............................................. ....................
FIRE DAMAGE (Any one fire)
:................................................
50000
........
:................................................................::.........................
MED. EXPENSE (Any one person): $
................ .................... ..................................................
............
.................
50.. 0..0
...................................................................:...........................................................................................
::AUTOMOBILE LIABILITY COMBINED SINGLE
.......... : LIMIT $
ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
HIRED AUTOS
NON -OWNED AUTOS
GARAGE LIABILITY
......:.......................
............................
.....
EXCESS LIABILITY
UMBRELLA FORM
OTHER THAN UMBRELLA FORM
.
.......................................................
WORKER'S COMPENSATION
B AND
EMPLOYERS' LIABILITY
OTHER
NWC247270.01
....................................................................:....
ll.........
.............Operations................................................................................
DESCRIPTION OF OPERATIONS�LOCATIONSMEHK:LES/SiPECUIL ITEMS
BODILY INJURY
(Per person)
...............................
BODILY INJURY
(Per accident)
PROPERTY DAMAGE
.:..................................
:EACH OCCURRENCE
..................................
AGGREGATE
STATUTORY LIMITS
.......:.........................................:.
EACH ACCIDENT :$
..................................................
DISEASE - POLICY LIMIT $
.............................. :................
:...
DISEASE - EACH EMPLOYEE $
1000000
..................
1000000
...................
1000000
:::::::'SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
>: •EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO
of La Quints <'s MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE
Bolt 1504 "' LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR
LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES.
La Quints CA 92253
Paul W. Lewis
May 3.1, 1995
T. BASS CO.
79595 Marigold Ln
La Quinta, Ca 92253
Dear Business Owner:
Prior to approving your business license with the City of La
Quinta, we have found it is necessary that you provide us with a
required HOME OCCUPATION PERMIT. For the moment your .business
license, remains inactive (NOT VALID) until we receive a copy of
your paid HOME OCCUPATION PERMIT.
Should you have any questions in this regard, please, do not
hesitate to contact me at (619) 777-7000.
Sincerely,
Missy Ceballos
Finance Department
Business License Division
0
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