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Witthaus140 Z-O/ 5r oorz-- � tI P.O. Box 1504 78-495 CALLS TAMPICO LA QUINTA, CALIFORNIA 92253 (760) "v' �q FAX (760) 777-7101 APPLICATION FOR HOME OCCUPATION OF A BUSINESS 1jq-,Pd2 FEE 1 70.00INSPECTION DATE: ease 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 4;k]&) 4 V'P &A6&ab ab PHONE: MAILING ADDRESS: t`©` 9 a0!�i5 (IF DIFFERENT FROM ABOVE) PROPERTY OWNER: , M-) Y)M V I<-1 TYPE OF RESIDENCE, (SINGLE, MULTIPLE, MOBILE HOME, ETC.): `D ��.� TYPE OF BUSINESS: -X U—t\r BRIEF DESCRIPTION OF HOW THE BUSINESS WILL OPERATE: MCk. IUP_`In�T� 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 - 125SQ FT.): DESCRIPTION OF MACHINERY, EQUIPMENT AND SUPPLIES BEING USED IN 'ITE OPERATION: g CIN'A� NAt OW"") - 6k •(t7 C[ 1`NrP Y :� a6VA (Vvt I HAVE READ, UNDERSTAND, AND AGREE WITH THE CONDITIONS BY WHICH A HOM 00C4UPATHOIS ALLOWED. (CONDITIONS ATTACHED). LC,ZIAPLTURE DATE IF APPLICANT IS OTHER THAN THE PROPERTY OWNER, AUTHORIZATION OF OWNER OR RENTAL/LEASING AGENT IS REQUIRED. OWNER/AGENT SIGNATURE DATE . _ .. AGENT COMPANY NAME CONTACT PH. # DATE IMPORTANT: 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. BUILDING AND SAFETY DEPARTMENT/CODE COMPLIANCE DIVISION: APPROVED DENIED SPECIAL CONDITIONS OFFICER h ? I.D. # i DATE Z Y PLEASEREAD! Please cont t your Homeowner's Association prior to paying for your Home Occupation P mit. Your Homeowner's Association may restrict or prohibit home basusluesses. I HAVE READ AND UNDERS'T'AND THIS STATEMENT. ,Signa 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 Quinta, 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 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 EXPIItATION DATE FOR WORKER'S COMPENSATION IS REQUIRED TO PROCESS TYIIS 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, 1 will provide the City with a policy or certificate copy within ten (10) days of the change in requirements. AllPt4eANT SIGNATURVE DATE WARNING: Failure to secure Worker's Compensation coverage is unlawful, and shall subject an employer 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. CPS, LA re Aj ii C -L 16 vol �:t t1w i, "I - -7!,;]f_=: t me a lzri in. 1- 0 rd p §11 vr lok aw. c ty = AApLICANTNAMES, (LiRtAU*mutz's- Pffrtow;, wTi A4_ "1,2:%: 14 OWE. PE. opmjwNc �J (STK(IL.F_ MULTI, FIC (W J�USe4ESS. 0 E C, R iy 9 -1) IN 'tt (),p S INVOI.,Vu .40bo pMON -RE FOOT&GE P P moo�p; �vxrll CARAGRY LjSj�W_j; FLOO.t AIt A. I A -D S01 iA R _rAGr )f APUFA OF BUSfN.FqS AC11wry [_,�i Homs. Bfa�f, Q )&,T A DiSj, jqpTr.o.�-j OWWTON: qm,r-Hmq TFm.PR(VmTrn' ALTTH01-11 "AD, U"ERSTAND, AND AG, I c -1 I �VA�Lv'?!� ELI AG R7 SZ ACR�TWKIAKY INWORTAXE.- UMSY. OR NNIS .2i00 �i3 BF GROUNDS FOR DTT"G YOTM 110M OCCUPATION; FAM)RIC TO COMPLY WTIIf THU ( MNI)ITIONS LIDILD ON TM ;.rr =,Cm P'% C'r sn-& f t -3RD' G -R ("T MD","FOR. RTVOK.':MON a t? w4i*r. Mil"olt,10, MD SAFF- J)j hflPPlr)VF-D--V— DENIED SiMVIAL CONONTIONS Permit Number: H02015-0012 Applied: 3/20/2015 Issued: Status: APPROVED Parent Permit: Parent Project: Approved:3/20/2015 Finaled: Description: MEHGAN WITTHAUS Site Address: 51780 AVENIDA VELASCO City, State Zip Code: LA QUINTA, CA 92253 Applicant: MEAGHAN WITTHAUS Owner: ERIK FLEISHAM Contractor: <NONE> Details: LIST OF INSPECTIONS SEQ SCHEDULED DATE COMPLETED DATE TYPE INSPECTOR RESULT REMARKS ICS -- -•-_ ME MOISES 3/23/2015 OCC O ATION RODARTE 10:00-10:30 A, M, Printed: Friday, 20 March, 2015 1 of 1