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• FEE $35.00
CITY OF LA QUINTA
78-495 Calle Tampico, P. O.Box 1504, La Quinta
HOME OCCUPATION PERMIT
I IIIIII VIII IIII IIII
37
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 NAMEPHONE
PROPERTY OWNERso . f'�r�r s� PHONE �&Iq)
PROPERTY ADDRESS G,W e!5Z,1.:1,17W t '.V
MAILING ADDRESS C�
TYPE OF RESIDENCE (single, multiple, ffiobir home, etc.)
TYPE OF BUSINESS ,/ &, r /�,�a��� �f���¢ 1"i�o--y- s�i^o���SD•r
BRIEF DESCRIPTION OF HOW THE BUSINESS WILLOPERATE
�- ��/Ylr/L�.�s�--co aP �✓/GL, ' �r�i �.r7�cGr , �+ �lr.��,:rr �� /Jroa�.crS:.✓ oar �
NUMBER OF PERSONS INVOLVED IN 'BUSINESS
LIST NAME OF PERSONS EMPLOYED
SQUARE FOOTAGE OF USABLE FLOOR AREA
IN HOUSE ( EXCLUDE GARAGE ) /o X/ z -
LOCATION AND SQUARE FOOTAGE OF AREA
OF BUSINESS ACTIVITY IN HOME
(EXAMPLE, "BEDROOM -125 S.F.")
DESCRIPTION OF MACHINERY, EQUIPMENT, AND SUPPLIES BEING USED IN THE
BUSINESS OPERATIONai
I HAVE READ, r ERSTAN�D, AND AGREE WI -THE CONDITIONS BY/ WHICH A
HOME OCC I5j&LOWED (CONDITIONS ATTACHED).
GNATURE
DA'
IF A,131PLICANT IS OTHER THAN PROPERTY OWNER, AUTHORIZATION OF OWNER
OR AGENT IS REQUIRED.
/ 3 /5195
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.
Buildin and Safet De artment
• APP VED DENIED CONDITIONS ATTACHED -&
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TaT 4 4a.Qa1am
78-495 CALLE TAMPICO — LA QUINTA, CALIFORNIA 92253 - (619) 777-7000
FAX (619) 777-7.101
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 Se on�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 92253
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