MindellPF
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P.O. Box 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
(760) 777-7000
FAX (760) 777-7101
APPLICATION FOR HOME OCCUPATION OF A BUSINESS
Fjg 74 00 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: (List all owners, partners, and/or corporation officers
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PROPERTY ADDRESS: 5��7 a 0 A V 'il`-/ty4- CW Rq~ ]'HONE: -76 D~ S F b4 d 7
MAILING ADDRESS: 7 c `l OS P L G 4 WA Y I i f V f a 3 O " A L, v"74` 09` . Td P s3
(IF DIFFERENT FROM ABOVE)
PROPERTY OWNER: N M (ND�LL
TYPE OF RESIDENCE, (SINGLE, MULTIPLE, MOBILE HOME, ETC.): S (ivG
TYPE OF BUSINESS:
BRIEF DESCRIPTION OF HOW THE BUSINESS WILL OPERATE: .m 0(C QP06P + (AL
'0r c-1Ve?Y C2r EFL r 5- W OPL C < s + 5'Oe Vl CCs'
NUMBER OF PERSONS INVOLVED IN BUSINESS:
SQUARE FOOTAGE OF USABLE FLOOR AREA IN HOUSE (EXCLUDE GARAGE): Ja 0 b
LOCATION AND SQUARE FOOT -AGE OF AREA OF BUSINESS ACTIVITY IN HOME (EX. BEDROOM -
125 SQ FT.): `� D -D b a
DESCRIPTION OF MACHINERY, EQUIPMENT, AND SUPPLIES BEING USED IN THE BUSINESS
OPERATION: _
IRAUIC 1 MACP (4, F �(�FNnil f' F�?✓l P/►'l Fn:
I HAVE READ, UNDERSTAND, AND AGREE WITH THE CONDITIONS BY WHICH A
HOMATION IS ALLOWED. (CONDITIONS ATTACHED).
APPLICANT'S SIGNATURE DATE
IF APPLICANT IS OTHER THAN THE PROPERTY OWNER, AUTHORIZATION OF OWNER OR
RENTAL/LEASING AGENT IS REQUIRED.'
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OWNER/AGENT SIGNATURE
AGENT COMPANY NAME
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DATE
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 ��- I.D. # -- DATET� o -
PLEASE READ!
Please contact your Hom wner's Association prior to paying for your Home
Occupation Permit. Your omcowxier•'s Association may restrict or prohibit
home based businesses.
I HAV"
STATEM
Signature
I'.
AND UNDERSTAND THIS
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
I hereby affirm under 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 EXPIRATION DATE FOR WORKER'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 Section 3700, I will provide the City with a
policy or certificate copy within ten (10) days of the change in requirements.
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APPLICANT SIGNATURE 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.
Description: RETAIL / TENNIS PRODUCTS
Type: HOME OCCUPATION Subtype: STND Status: SUBMITTED
Parcel No: 773291026 Site Address: 52720 AVENIDA CARRANZA LA QUINTA,CA 92253
Subdivision: SANTA CARMELITA VALE LA QUINTA
UNIT 16
Lot Sq Ft: 0 Building Sq Ft: 0
Valuation: $0.00 Occupancy Type:
No. Buildings: 0 No. Stories: 0
Block:154 Lot:14
Zoning:
Construction Type
No. Unites: 0
Details: MAIL ORDER & LOCAL DELIVERY OF TENNIS PRODUCTS & SERVICES.
Applied: 11/13/2014 PJU
Approved:
Issued:
Finaled:
Expired:
Printed: Thursday, November 13, 2014 4:54:52 PM 1 of 2 r,.#? S YS TcMS
DESCRIPTION ACCOUNT QTY AMOUNT PAID PAID DATE RECEIPT # CHECK # METHOD PAID BY CLTD
BY
HOME OCCUPATION 101-0000-42447 0 $70.00 $70.00 11/13/14 R2847 DEBIT IAN MINDELL PJU
Total Paid for HOME OCCUPATION: $70.00 $70.00
PARENT PROJECTS
Printed: Thursday, November 13, 2014 4:54:52 PM 2 of 2 CR
._ - SY57EM5