SMITH1,FEE $35.00
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CITY OF LA QUINTA
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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
PROPERTY OWNER �n 'Swil ,
PROPERTY ADDRESS
MAILING ADDRESS
TYPE OF RESIDENCE (single,
TYPE OF BUSINESS
BRIEF DESCRIPTION OF HOW Tl
PHONE
PHONE
pie, mobil h6me; 'etc.)
BUSINESS WILL OPERATE
NUMBER OF PERSONS INVOLVED IN BUSINESS
LIST NAME OF PERSONS EMPLOYED
• SQUARE FOOTAGE OF USABLE FLOOR AREA
IN HOUSE (EXCLUDE GARAGE) /2,,5,r ft.
LOCATION AND SQUARE FOOTAGE OF AREA
OF BUSINESS ACTIVITY IN HOME
(EXAMPLE, "BEDROOM -125 S.F.")
DESCRIPTION OF MACHINERY, ;.Quip NT,, AND SUPPLIES BEING USED IN THE
BUSINESS OPERATION �, a1'yJlt?__
I HAVE READ, UNDERSTAND, AND AGREE WITH THE CONDITIONS BY WHICH A
H049 pCCUy4fTION IS ALLOWED (CONDITIONS ATTACHED) . _ ,, �,-i,
APPLIC;WT SIGNATURE
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.
• Buil n and Safety Department
APPR DENIED 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
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 700.
Date: 1 IZ6 q_5 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 QUINTA, CALIFORNIA 92253
JAN 20 '95 12:21 KEN SMITH CPA P.2/3
a KENNETH R. SMITH
CERTIFIED PUBLIC ACCOUNTANT
January 20, 1995
City of LaQuinta
Reference: Home Based Business
Gentlemen:
I hereby authorize Mr. John Taylor to operate a janitorial service out of my residence at
44-580 Saffron Ct., LaQumta, CA.
I certify that I am the legal owner of the residence and that my permanent residence is
6618 196th St SE, Snohomish, WA 98290
If you have any questions regarding this matter please feel free to give me a call at
(206)481-9321.
Sincerely,
• Kenneth R- Smith
Certified Public Accountant
•
6618 196TH ST. S.E. • SNOHOMISH, WASHINGTON 98290 - (206) 481-9321
01/20/95. 11:52 TX/RX N0.0207 . P.002 0
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1.
4 BUS. LIC. NO.
1995 BUSINESS LICENSE APPLICATION FORM
*************** ** * ******
*APPROVED BY
* DATE
********************* ******
PROOF OF WORKERS COMPENSATION INSURANCE IS REQUIRED PRIOR TO ISSUANCE
IS THIS BUSINESS LOCATED AT YOUR HOME: YESy NO
2.
Business Name: 910A~
mo`" & �20QEZ
A13"Ae ,10:3mmice-c
3.
Business Address
:590 !'ZWjfW4 4.
Mailing Address:
01-221
5.
Business Phone:
(�) =
6.
Owned By: CORPORATION PARTNERSHIP INDIVIDUAL
7.
If Corporation or
Partnership: TAX I.D.#
8.
If Individual Owner: Social Security # J�
" q✓�- ^Q�3q
9.
Name of Owner
O % r
Title:
Or Officers
&0.
11.
Type of Business: �Jnrnir 1 %
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:
S
B. PreviouGross Receipts for Established Businesses:
s
***********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.
_J0 Z4
1,
gnature Title Da
• Send Completed Form To:
i CITY OF LA QUINTA.
BUSINESS LICENSE DIVISION
78-495 Calle Tampico
P. 0. Box 1504
La Quinta, CA 92253
to