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CITY OF LAQUJN A 'S r OF!"A Qum-f,a
DESIGN &DEVELOPMWOEP4Z4E OCCUPATION OF A BUSIN §9A"NI)L4,M�`-LGN-ircffG
PERMIT# 1402Q-0-00lf INSPECTION DA
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:
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Address:
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Phone:
Email:
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Type of residence:
Square Footage:
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Type of Business:
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Brief Description of the Business Operation:
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Location and Square Footage of Business in Home: (Ex. Bedroom 120 SF)
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Number of Persons Involved in Business:
_ 2
Description of Machinery, Equipment, and Supplies Being Used:
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I HAVE READ, UNDERSTAND, AND AGREE WITH THE ATTACHED CONDITIONS WHICH A HOME
OCCUPATION PERMIT IS ALLOWED.
APPLICANTOSIG NATURE
DATE
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IF APPLICANT IS OTHER THAN THE PROPERTY OWNER, A SIGNED AUTHORIZATION FROM OWNER
OR RENTAULEASING AGENT IS REQUIRED.
OWNER -AGENT SIGNATURE DATE
AGENT COMPANY NA-N-IF 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
I HAVE READ AND UNDERSTAND THIS STATEMENT.
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CODE COMPLIANCE USE ONLY
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APPROVED DENIED SPECIAL CONDITIONS
OFFICER DA"CE
78495 CALLE TAMPICO - LA QUINTA, CA 92253 - 760-777-7000
WW W.LA UINTACA,GOV
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 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 government code or Section 7284 of the Revenue and Taxation Code, shall GqMjete artd-signa
declaration that states the followin -
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 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 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.
"A a,
APPLICANT SIGNA URE
7 1��2�
DATE
WARNWNG: 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 attorneys fees
may be assessed to you as provided In Section 3706 of the Labor Code.
78495 CALLE TAMPICO — LA QUINTA, CA 922S3 760-777-7000
WWW.LAQUINTACA.GOV