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BUS. LIC. NO.
1994 BUSINESS LICENSE APPLICATION FORM
*APPROVED BY t
* DATE U - -7
......PROOF OF WORKERS COMPENSATION INSURANCE IS REQUIRED........
1. IS THIS BUSINESS LOCATED AT YOUR HOME: YES_ NO
2. Business Name:
3. Business AddressQIL� 4. Mailing Address: 0
5. Business Phone:(
6. Owned By: CORPORATION PARTNERSHIP INDIVIDUAL
7. If Corporation or Partnership: Tax I.D.#
8. If Individual Owner: Socia Security # Li2 E --9Z -2 z q j
9. Name of Owner D Title:es�
Or Officers
10. Type of:. Business: ;4-1 tet
;s� &L 'scoU�j r.
11. IF YOU ARE A FOOD VENDOR, DO YOU HAVE A COU`EALTH PERMIT:
YES NO
'12. SHE Resale 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:
$
B. Previous Year Gross Receipts For Established Businesses:
********GOOD ONLY FOR JANUARY 1,1994 THRU DECEMBER 31,1994*******
I HEREBY CERTIFY that all the information supplied by me is correct and
any licenses req red by the County, State or Federal Government have been
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issued to 'me aAre in full force and effect.
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Title
Submit Form To:
CITY OF LA QUINTA
BUSINESS LICENSE DIVISION
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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:
u
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 .
1/ 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 sutject to
the worker's c mpensation 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
MAILING ADDRESS - P.O. BOX 1504 - LA OUINTA; CALIFORNIA 82253 ��
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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 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 becom subject to
the worker's compensation provisions of Section 3700
Date: O Applicant:
WARNING: Failure to. secure workman's compens ion 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