CordanoFEE $70,00
01
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P.O. Box 1504
75-495 CALLS TAMPrcO (760) 777-7000
LA QUINTA, CALIFORNIA 92253 FAX (760) 777-7101
APPLICATION FOR HOME OCCUPATION OF A BUSINESS
INSPECTION DATE:
Please 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: (Iasi all owners, partners, and/or corporation officers _.
CL.4LA,n 5 LkJ TA
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PROPERTY ADDRESS::
MAILING ADDRESSAWkL k,),A
�"l (f.I' I3EFFI:�t (z� I FROM ABOVE}
PROPERTY OWNER: �'. 'rAVV14-) �f' ir(� i ?� 7 !!a?� �).V OI L
TYPE OF RESIDENCU, Sli�Ci MULTIPLE, MOBILE OME, ETC.): r'
TYPE OF BUSINESS: f .(I I SIC"f�`� ti_ . l T uv S
BRIEF DESCRIPTION OF HOW THE BUSINESS WILL OPF.RATII:
NUMBER OF PERSONS INVOLVED IN BUSINMSS: I 1 Vl L-r^
SQUARE FOOTAGE OF USABLY FLOOR AREA IN HOUSE (EXCLUDE GARAGE): � 4
LOCATION AND SQU 00' GE OF AREA OF 13ETS CTI VCI'Y IN HOME (EX. BEDROOM -
125 SQ FT.):
DESCRIPTION OF MACHINERY..EQUIPMGMi' AND SOPPLIES BEIN USED IN T E BU INFSS
OPERATION: (tom t� = [, , B
�t 1#YZr1 n Yeti T �C
I-gAVjIr READ, UNDERSTAND, AND ACREK,W111I THE CONDITIO BY RICH A
' 110ME OC tT1' '1'10 I ALLOWED. (CO t)1:1'1 NS 7"1'ACI1ED).
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' AP I 1v7'S SIGNATURE DATE— _
L)
IF APPLICANT IS OTHER THAN THE PROPERTY OWNER, AUTHORIZATION OF OWNER OR
RENTAL/LEASING AGENT IS REQUIRED.
CODE COMPLIANCE DIVISION
HOME OCrUPATION APPROVED
NFL 1
J
OWNEIVAGENT SIGNATURE DATE
AGENT COMPANY NAME CONTACT PH. # DATE
IMPORTANT: FALSE OR MISLEADING INFORMATION SHALT. BE GROUNDS FOR DENYING
YOUR HONE OCCUPATION; FAILURE TO COMPLY WITH THE CONDITIONS LISTED ON THE
ATTACHED PAGE SHALL BE GROUNDS FOR REVOCATION OF PERMIT.
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BUILDING AND SAFETY DEPARTMENT/CODE COMPLIANCE DMSION:
APPROVED_
DENIED
SPECIAL CONDITIONS
OFFICER I.D. # _ . _.... DATE
Please contact your Homeowner's Association prior to paying for your Home
Occupation Permit. Your Homeowner's Association may restrict or prohibit
home based businesses.
I HAVE READ AND UNDERSTAND THIS
-STATEMENT.
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 Quints, 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
WORKER'S COMPENSATION DECLARATION QIA
I hereby d5rmtnder 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 V(PIRATION DATE FOR WORKER'S COMPENSATION IS REQUIRED TO
PRO�E HIS APPLICATION.
I certify that in the performance of nary 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, I will provide the City with a
policy or certificate copy within ten (10) days of the change in requirements.
APPLICANT Sl NA ,, DATE
WARNING: Failure to secure Worker's Compensation coverage is unlawful, and shall subject an employer
to criminal penakies'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.