BUSS40"
I IIIIII VIII IIII IIII
66
Tdf 4 4 (4" -
P.O. Box 1.504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92247
COMMUNITY SAFETY DIVISION
HOME OCCUPATION PERMIT
Permit Number: 108=0000051`8
-(760) 7 77-705 0
FAX (760) 777-7011
Please read each condition listed on the attachment in this packet to see if the proposed activity complies
with the City's Home Occupation Regulations.
Applicant name(s): (List all owners, partners, and/or corporation officers) MICHELLE BUSS
AZ..
W v
Property address: 79720 NORTHWOOD Phone: oewn
Mailing address: 79720 NORTHWOOD /n Q
�•
F
Property owner: c� FB �' '01
Type of business: jewelry design �iq0 ��Q� `. 1�L
�F oG D �.
Brief description of how the business will operate: OF �Nr
•
quare footage of usable floor area in house (exclude garage) 300
Location and square footage of area of business activity in home (Example: Bedroom — 125 sq ft.) kitchen, 100
Description of machinery, equipment, and supplies being used in the business operation:
,.,
I HAVE READ, UNDERSTAND, AND AGREE WITH THE CONDITIONS BY WHICH A HOME
OCCUPATION IS ALLOWED. (Conditions Attached)
AP ICANT SIGNATU DATE
If applicant is other than the property owner, authorization of owner or rental/leasing agent is required.
hhemdky �-1i-v
Your inspection has been scheduled for Home Occupation Inspection between 2:00-2:30 PM. )Your Inspector
will be Kevinn N eredithl
--------------------------------------------INSPECT USE ONLY -----------------------------
El APPROVED
❑ DENIED Inspector Signature Date
CE HP
P.O..Box 1504
78-495 CALLE TAMPICO (760) 777-7000
LA QUINTA, CALIFORNIA 92253 FAX (760) 777-7101
APPLICATION FOR HOME OCCUPATION OF A BUSINESS
FEE $70.00 INSPECTION DATE:
Please read each condition listed on the attachment in this packet to see if•the proposed .
activity complies with the City's Home Occupation Regulations.
APPLICANT NAMES: (List all owners, partners, and/or corporation officers
PROPERTY ADDRESS: ?-0ci'ZC� (1�ov o®� PHONE: �-CQc� – Z–o��' 11)eA,�`
W
MAILING ADDRESS: VeOr p Ott (IFDIFFERENT FROM ABOVE) `/�v
�^ccCGI S�� (O
PROPERTY OWNER:
.TYPE OF RESIDENCE, (SINGLE, MULTIPLE, MOBILE HOME, ETC.):._ ,S�
TYPE OF BUSINESS:
c91_; _t a__q .c.9 � S eC e2etscLr�
BRIEF DESCRIPTION OF HOW THE BUSINESS WILL OPERATE: S S �rcd
—If _�• _� c� Tf�� pl�ne,S� S«.r,Pl��y itCevk�
NUMBER OF PERSONS INVOLVED IN BUSINESS:
SQUARE FOOTAGE OF USABLE FLOOR AREA IN HOUSE (EXCLUDE GARAGE):
LOCATION AND SQUARE FOOTAGE OF AREA OF BUSINESS ACTIVITY IN HOME (EX. BEDROOM
125 SQ FT.):
DESCRIPTION OF MACERY, EQUIPMENT, AND SUPPLIES BEING USED IN THE BUSINESS
OPERATION: X/ar1ar, �✓ /
I HAVE READ,.UNDERSTAND,'AND AGREE WITH THE CONDITIONS BY WHICH A
HOME .00CUPATION IS ALLOWED. (CONDITIONS ATTACHED).
APP ICANT'S SIGNATURE DATE '
IF APPLICANT IS OTHER THAN THE PROPERTY OWNER, AUTHORIZATION OF OWNER OR
• . RENTAL/LEASING AGENT IS REQUIRED.
T
OWNER/AGENT SIGNA DATE
AGENT COMPANY NAME CONTACT PH. # DATE
1WO. RTANT: FALSE OR MISLEADING INFORMATION SHALL BE GROUNDS FOR DENYING
YOUR HOME OCCUPATION; FAILURE TO COMPLY WITH THE CONDITIONS LISTED ON THE
ATTACHED PAGE SHALL BE GROUNDS FOR REVOCATION OF PERMIT.
i
PLEASE READ!
Please contact your Homeowner's Association prior to paying for your Home
Occupation Permit. Your Homeowner's Association may restrict or prohibit
home based businesses.
WORKER'S COMPENSATION
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 section on this page: "I Certify that......".
If your business is being operated.from your home in La Qwnta, a Home Occupation Permit is required before a
business license is issued.
If you have any questions, please contact the Code Compliance Division at 777-7050.
Every employer who applies for any license or 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 declarations:
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: Expires:
A COPY OF.SAID POLICY OR CERTIFICATE OF CONSENT SHOWING THE AMOUNT OF
COVERAGE AND EXPIRATION DATE FOR WORKER'S COMPENSATION IS REQUIRED TO
PROCESS T S 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 in 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, I will provide the City with a
policy or certificate copy within ten (10) days of the change in requirements.
APPLICANT SIGNA DATE
WARNING: Failure to secu Worker's Compensation coverage is unlawful, and shall subject an employ&r
to criminal penalties'and civil fines up to $100,000. In addition to the cost of.compensation, damages,
interest, and attorney's fees may be assessed to you as provided in Section 3706 of the Labor Code.