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FEE $35.00 BgO(L�� ��TY
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!ZLL
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PHONE 6/9 •
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PROPERTY OWNER
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PHONE
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PROPERTY ADDRESS
BLS07
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MAILING ADDRESS
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TYPE OF RESIDENCE
(single, multiple,
mobil home, etc.)
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TYPE OF BUSINESS
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BRIEF DESCRIPTION
OF HOW THE BUSINESS
WILL OPERATE
t)ll
NUMBER OF PERSONS INVOLVED IN BUSINESS /
LIST NAME OF PERSONS EMPLOYED
• SQUARE FOOTAGE OF USABLE FLOOR AREA _
IN HOUSE (EXCLUDE GARAGE) ___Z,j
LOCATION AND SQUARE FOOTAGE OF AREA
OF BUSINESS ACTIVITY IN HOME
( EXAMPLE , "BEDROOM -125 S.F.") IDCA) / 7,P -S', F.
DESCRIPTION OF MACHINERY, EQUIPMENT, AND SUPPL ES BEING USED IN THE
BUSINESS OPERATION CG LLL L-4rL 91kor/e
r / L L GA,3 /n/ d -n -
I HAVE READ, UNDERSTAND; AND AGREE WITH THE CONDITIONS BY WHICH A
HOME O gJYAT.ION�IS ALLOWED (CONDITIONS ATTACHED).
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APPLIMT SIGI*TURE DATE
IF APPLICANT IS OTHER THAN PROPERTY OWNER, AUTHORIZATION OF OWNER
OR AGENT IS REQUIRED. _
_ IA -4" . / - z1�i- 9%-
OWNER/AGENT SIGNATUi)E 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
PERMIVnq
• BuildandS - afe-ty Department
APPROVED DENIED CONDITIONS ATTACHED
T4'y/ 4 fiaa�,rw
78-495 CALLE TAMPICO — LA OUINTA, 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 3.700 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
THIIS APPLICATION.
y 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 37/00/.
Date: ' .Z 5 `� S Applicant: (N
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 QUINTA; CALIFORNIA 92253 •
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ca,--74
4u�GitiGv
BUS. LIC. NO.
1995 BUSINESS LICENSE APPLICATION FORM
*APPROVED BY r
* DATE — 3 _ g► j
****************************
PROOF OF WORKERS COMPENSATION INSURANCE IS REQUIRED PRIOR TO ISSUANCE
1. IS THIS BUSINESS LOCATED AT YOUR HOME: YES NO
2: Business Name: ,Q22T2� S!d
3. Business Address: 4. Mailing Address:
5 7 44-OW rA-4
5. Business Phone: () S6 7 - 7 q LZ
6. Owned By: CORPORATION PARTNERSHIP INDIVIDUAL
7. If Corporation or Partnership: TAX I.D.#
8. If Individual Owner: Social Security #I
,� / l
9. Name of Owner ��� %t/i9-CJl A af4A/ Title: 6).tirc�
Or Officers
•10.
11.
Type of Business: /g "e-Cw..
IF YOU ARE A FOOD VENDOR, DO YOU HAVE A COUNTY HEALTH PERMIT:
YES NO
12. SBEResale Number:
13. BUSINESS LOCATED WITHIN THE CITY OF LA QUINTA (Does Not Apply To Building
Contractors):
A. Estimated Gross Business Receipts for New Businesses Only:
'000
B. Previous Year Gross Receipts for Established Businesses:
***********GOOD ONLY FOR JANUARY 1, 1995 THRU DECEMBER 31, 1995**********
I 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.
Signatmf�
• V
9
Title Date
Send Completed Form To:
CITY OF LA QUINTA
BUSINESS LICENSE DIVISION
,78-495.Calle Tampico
P. 0. Box 1504
La Quinta, CA 92253