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Alimohammadi - Apt 114•D AD JUN 2 2 2020 CITYOFLAQUINTA 1 0ME OCCUPATION OF A BUSI Nffn &DE E 0 M NTDEPARTMENT PER MIT �-}OZDZ0— 00,701 2-tNSP£CTION DA TIME Please read each condition listed can the attachment in this Packet to see if the Proposed home business cQMP]ies with the City's home Occupation regulations. NEW APPLICATION $105.00 LOCATION CHANGE $55.09. Applicant Names: Add ress: Phnna- t 760) 2q7- GL 7& Type or residence: 0. rrve rid" Email: Co square Footage: 41 7l SF Type of cw4 . 'note � ► ii ` Brief Description of the 8u$iness C)peration: — rLocation and Square Footage of business in Hor4e-. (Ex. Bedroom lidSF) 100 5 IVuml�er of Persons Involved in Business: --- —�- Description of Machinery, Equipment, and Suppiies Being Used; I HAVE READ, UNDERSTAND, AND AGREE WITH THE ATTACHED CONDITIONS WHICH A HOME OCCUPATION PERMIT IS ALLOWED. ,A -- - -.-- _ _�� •+% Ai7P�.ICANT SIGNATURE � ©ATE r ' IF APPLICANT IS OTHER THAN THE PROPERTY OWNER, A SIGNED AUTHORIZATION FROM OWNER OR RENTAL/LEASING AGENT IS REQUIRED. LV DATE SAS �-sm_ AGENT COMPANY NAME CONTACT PHONE PLEASE CONTACT YOUR HOMEOWNER'S ASSOCIATION PRIOR TO PAYING FOR YOUR HOME OCCUPATION PERMIT. YOUR HOA MAY RESTRICT OR PROHIBIT A HOME -BASED BUSINESS. IMPORTANT: FALSE OR MISLEADING INFORMATION SHALL BE GROUNDS FOR DENYING YOUR APPLICATION; FAILURE TO COMPLY WITH THE CONDITIONS LISTED ON THE ATTACHED PAGE SHALL BE GROUNDS FOR REVOCATION OF THIS PERMIT APPROVED_ 6�� CER I HAVE READ AND UNDERSTAND THIS STATEMENT. �v CODE COMPLIANCE USE ONLY €DENIED DATE SPECIAL CONDITIONS WORKER'S COMPENSATION If your company has employees, a copy of the ►Norkman's Compensation Policy must actiompany 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 can 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 Cade Compliance Division at 760.777.7063. a busines Every employer who applies for any license or renewal of any license for,s issued pursuant to Section 37101 of the government code or Section 7284 of the Revenue and Taxation Code, shall romle a an �4;1+ jI hereby affirm under penalty of perjury, one of the following declarations: ! _ I I have: and will maintain a certificate of consent to self -insure for W Compensation, as Worker's 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 lousiness 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 of any business activities for which this license is issued, I shall not employ P Y an y 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 previsions of Section 3700, I will provide the City with a policy or certificate copy within ten(10) days of the change in requirements. APPLICANT SIGNATURE DATE W►ARBI_N.S= 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.