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SZALEY, FEE $35.00 69 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 5A6LtA9_ S PHONE PROPERTY OWNER R a r P. S z w 1 w PHONE e 1 sq PROPERTY ADDRESS - R"iyc S�� F M,rr,c_1,� Ane- Lr� ©�;��►� MAILING ADDRESS p, n _ g o x TYPE OF RESIDENCE (single, multiple, mobil home, etc.) TYPE OF BUSINESS T- m BRIEF DESCRIPTION OF HOW THE BUSINESS WILL OPERATE 0 NUMBER OF PERSONS INVOLVED INBUSINESS 1 LIST NAME OF PERSONS EMPLOYED- • SQUARE FOOTAGE OF USABLE FLOOR AREA IN HOUSE (EXCLUDE GARAGE) iOcL LOCATION AND SQUARE FOOTAGE OF AREA OF BUSINESS ACTIVITY IN HOME pFF' (EXAMPLE, "BEDROOM -125 S.F.") DESCRIPTION OF MACHINERY, EQUIPMENT, AND SUPPLIES BEING USED IN THE BUSINESS OPERATION (►�,,.�pu+P�+ -1-� ru1I�; }ems¢. , ,o4�a✓�� �-4�X m Pt&(\ *,N,_-, I HAVE READ, UNDERSTAND, AND AGREE WITH THE CONDITIONS BY WHICH A HOME OCCUPATION IS ALLOWED (CONDITIONS ATTACHED). � a4AL <at7_AJl� / - 3 /-S ICANT SIGNATURE // DATE.. IF APPLICANT IS OTHER THAN PROPERTY OWNER, AUTHORIZATION OF OWNER OR AGENT IS REQUIRED. /AGE ff SIGNATURE 3i- s 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. • B--==-n-=and Safety Department APPROVED DENIED CONDITIONS ATTACHED ICY -1/ y1_3 (q �� T-/dy- 4 4a Qu&M 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 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 REOUIRED TO PROCESS THI/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 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: I - I- g5 Applicant Sr�Gk V2. �v�+eie..pr� s cs 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