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-- CALIFORNIA --
JUN 16 2020
CITY OF lAQLIINiA �E OCCUPATION OF A BUSINESS
DESIGN &DEVELOPMENT DEPAR
PERMIT#- Ho 1410"* Go 307 INSPECTION DATE TIME
Please read each condition listed on the attachment in this packet to see if the proposed home business complies
with the City's Home Occupation regulations.
NEW APPLICATION $105.00 LOCATION CHANGE $55.00
Applicant Names:
R DGrt-
Address:
rjL Io AYevliclot Diaz
Phone: Email:
�Z 2 — 1 `Z -I-� ckrm rt-& G1 vyia i 1, c
Type of residence: Square Footage: `J
(S In �e -f MAY kome ?.1 LP
Type of Business:
fiaV1 a M 0,d-, puft
Brief Description of the Business Operation:
Z ma m-Fugurl oha I po#ffy OUT- Of WAY
Location and Square Footage of Business in Home: (Ex. Bedroom 120 SF)
ha(-� of �alr op 2 - 5q,� -�-�—
Number of Persons Involved in Business:
I
Description of Machinery, Equipment, and Supplies Being Used:
pofiery wheel) 1ki1n, glaz-:e-jyvf-eyy -t0o15).5 Ives
I HAVE READ, UNDERSTAND, AND AGREE WITH THE ATTACHED CONDITIONS BY WHICH A
HOME OCCUPATION PERMIT IS ALLOWED.
6�&. VLa4t—, IP-0Z0
L CANT SIGNATURE DATE
78495 CALLE TAMPICO - LA QUINTA, CA 92253 - 760-777-7000
W W W. LAQU I NTACA. GOV
IF APPLICANT IS OTHER THAN THE PROPERTY OWNER ASIGNED AUTHORIZATION FROM OWNER
OR RFNTALILEAS3NG AGENT IS REQI-HRED.
J4"- _(o &► o.-a-0
MN -ft AGENT SIGNAT7IRr.. I.):a ET
AGENT COMPANY NAME CONTACT PHONE
PLEA SIECONTACT YOUR HOMEOWNEWS ASSOCIATION PRIOR T,O'PAY ING FOR YOU Wl1WE
OCCIJPATION PERMIT. YOUR HOA MAY STRICT OR PROHIBIT A HOME-43ASED F.I•'USINESS.
IMPORTANT: FALSE OR MISLEADING IN FORM ATTON SHALL BE GROU�6DS FOR DENYING YOUR
APPI_TC'ATION; F.AILI URE-TEA COMPLY WITH THE CONDITIONS LISTED ON THE .ATTACHED PAGE
SKALL HE GROUNDS FOR REVOCATION OF THIS PERMIT
I HAVE READ AND UNDERSTAND TMS STATEMENT.
SIG' A I l IRF
CODE C"O MPLIANCE USE ONL Y
a a a a a■■■ a a a a a a a■■■ a■ a a a a a a a■■ a■■ a a a a
APPROVED
DENIED
OFFICER DATE
SPECIAL CONDITIONS
79495ICI: TAMPIC❑ QUI NTA, CA 92253 — 760-777-7000
W W W. LAp U I NTACA. GOV
WORKER'S COMPENSATION
'If your company 'has employees, a copy of the Workma.n's Compensation PolicyMust accompany "tine Business
License a,p;ol'ic-ation, indicating `dates of coverage a.nd dollar amount. This proof -of coverage rn�ust be received
before the'Busirress'tic-ense can be ;processed.
:If you do not'have employees, please "ch"eck the last section on this :page "'I certify that...."
If your businessis 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 760.777.7063-.
Every employer who applies for any license or renewal of any license for a business issued ;pursuant to Section
37101 of the govemmen't "code or Section 7284 of the Revenue and Taxation Code, shall complete and sign a
declaration that states the followins:
WORKER'S COMPENSATION DECLARATION
I hereby affirm u�nderpenalty 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 clura"ti"on of any business activities conducted for which this license is issued.
My Worker's "Compensation'Insurance carrier and policy number are:
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 ofany business activities for which this ;lice nse is issued, I shall
not employany person in any manner so as to become subject tothe worker's cornye'.ns-ation
iaws-of CaIi.tornia, 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.
Q AMC^
Z94- 2,
APPLI ANT 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
maybe assessed to you as provided in Section 3706 of the Labor Code.
78495 CALLE TAM°PICO w LA QUI NTA, CA 97253 - 760-777-7000
W W W . LAQLI I NTACA. GOV