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(Thomas Jackson MD) JacksonQta Qaa - CALIFORNIA JUL 18 2022 0 CITY OF LAQUINTA 9 DME OCCUPATION OF A BUSINESS DESIGN & DEVELOPMENT DEPARTM PERMIT# HOU12 —"S l INSPECTION DATE I Led r[2(,,N2z 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 $109.00 LOCATION CHANGE $57.00 Applicant Names: ( � G ls2e� G4 G (.� �4l'� �" `� r �k G � '9 � ' le_-�� v� V L .RC.v �•-eG� Address: l Phone: 7<o 0 -- �' — �d �o� mail: T l'4 �vw� ��cl.�oh rn d "ia I1.c Type of residence: Square Footage: Type of Business: /ld j,q� j c�� 5��Zoe s Brief Descriptiod of the Business Operation: � O , vj,gF 10,r� v h ,� ( ' /4--e—i- A y A&' F� ,.ter / . �,,� Js^��'� d,oc� � 7�-►��1"s � j . � �:�-� rtit.� n �- y�r w o w k s •r'sz � � f� ! � �fvo � Location cind Square Footage of Business in Home: (Ex. Bedroom 120 SF) C — 1 S C> 1 L ii-S i'4 - 2 2� f Ar;1- 3 7 S Number of Persons Involved in Business: - )bagel Lu(Ge_ allU o0k r✓uC'La f.,r• bP� Description of Machinery, Equipment, and Supplies Being Used: r I HAVE READ, UNDERSTAND, AND AGREE WITH THE ATTACHED CONDITIONS WHICH A HOME OCCUPATION PERMIT IS ALLOWED. APPLIC NT SIGNATURES DATE IF APPLICANT IS OTHER THAN THE PROPERTY OWNER, A SIGNED AUTHORIZATION FROM OWNER OR RENTAL/LEASING AGENT IS REQUIRED. , 2 . . (5' - fL, v 6 , - OWNER/ ENT SIGNATAO DATE 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 I HAVE READ AND UNDERSTAND THIS STATEMENT. e, G J SIGNATU CODE COMPLIANCE USE ONLY APPROVED DENIED AFICER SPECIAL CONDITIONS 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 complete and sign a declaration that states the following: 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 rcarrier and policy number are: Carrier: 3✓" �'��✓d �� Policy Number: 74 L&IF-6 A i 3 ()I+O Expires: ? (V2-3 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. l= 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. a44-4 K -2 � / APPLICANT SIGNATUOY 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. THE - HARTFORD Account Policy Information: Agency Name AUTOMATIC DATA PROCESSING INS AGCY Agency Code 76250937 Recipient Information Thomas Jackson MD Inc DBA Desert View Health 61730 MESA CT LA QUINTA CA 92253-7982 SUMMARY OF INSURANCE Account Policy Recap Policy Number Policy Term Premium Worker's Compensation Property and Casualty 76 WEG AT3PHD 07/14/2022 to $1,602 Insurance 07/14/2023 Company of Hartford July 16, 2022 Sum of Insurance Summary of Insurance (Continued) Worker's Compensation Summary of Insurance with Property and Casualty Insurance Company of Hartford A member company of The Hartford 07/14/2022 - 07/14/2023 Policy Detail: Worker's Compensation Policy States: CA Location 1 Premises Address: 61730 Mesa Court La Quinta CA 92253 Worker's Compensation Coverages: Employer's Liability Limits Limit Disease - Policy Limit $1,000,000 Bodily Injury —Accident $1,000,000 Disease - Each Employee $1,000,000 Class/Payroll Detail Class Description Class Code Payroll Location 1 - CA PHYSICIANS' 8834 $145.000 PRACTICES AND OUTPATIENT CLINICS - ALL EMPLOYEES - INCLUDING CLERICAL OFFICE EMPLOYEES AND CLERICAL TELECOMMUTER EMPLOYEES This Summary and its attachments provides a high level overview of policy coverages and does not include all conditions, limitations or exclusions. Please refer to the actual policy forms for detailed coverages, limits and deductibles. Sum of Insurance ADDRESS <Q / % O HOME OCCUPATION CONDITIONS A- Co►-CwY-+ ALL HOME OCCUPATIONS SHALL COMPLY WITH THE FOLLOWING CONDITIONS: 1. The establishment and conduct of a home occupation shall be an incidental d accessory use and shall not change the principal character or use of the dwelling unit involved: 2. Only residents of the dwelling unit may be engaged in the home occupation. 3. A home occupation shall be conducted only within the enclosed living area of the principal dwelling unit or within the garage provided no garage space required for off-street parking is used. The home occupation shall not occupy more than twenty-five percent of the combined floor area of the house and garage. 4. A home occupation shall not be conducted within a detached accessory structure, although materials may be stored in such a structure., 5. There shall be no signs, outdoor storage, parked vehicles or other exterior evidence of the conduct of the home occupation. Neither the dwelling nor the lot shall be altered in appearance so that it appears other than a residence, either by color, materials, construction, lighting, sounds, vibrations or other characteristics. 6. Electrical or mechanical equipment which creates interference in radio, television or telephone receivers or causes fluctuations in line voltage outside the dwelling unit shall be prohibited. 7. The home occupation shall not create dust, noise or odors in excess of that normally associated with residential use. 8. No sales activity shall be conducted from the dwelling except for mail order sales. The dwelling unit shall not be the point of customer pickup or delivery of products or services, nor shall a home occupation create greater vehicular or pedestrian traffic than normal for the district in which it is located. Exception: Musical instruction and academic tutoring where,not more than two students are present at the residence at the some time shoal be permitted. 9. Medical, dental or similar occupations in which patients are seen in the home are prohibited{ 10. All conditions attached to the home occupation permit shall be fully complied with at oil times.v Revocation or Suspension of Permit. The director of building and safety may revoke or suspend any permit for a home occupation if the director determines that any of the performance and development standards listed in subsection C of this section have been or are being violated, that the occupation authorized by the permit is or has been conducted in violation of any state statute or city law, or that the home occupation has changed or is different from that authorized when the permit was issued. Special Conditions:. BY SIGNING THIS DOCUMENT I AGREE THAT I HAVE READ, UNDERSTAND AND WILL COMPLY WITH ALL CONDITIONS. PRINT NAME OFFICER SIGNATURE 7� SIGNATURE DATE Conditions Per La Quinta Municipal Codes: 9.60.110, 9.160, 9.210.060 CONSENT TO INSPECT PRIVATE PROPERTY Name: Telephone No: -7 Property Address: 0 �a- �-� l 1h tL� PLEASE INDICATE IF YOU ARE: _ TENANT PROPERTY OWNER _PROPERTY MANAGER The undersigned herein consents to the City of La Quinta, Code Compliance Division Inspectors) right of entry to inspect all Yard Areas, building exterior(s), and/or interior(s), Including audio and video recording as needed to determine whether said property complies with local and state codes. The undersigned herein states that he/she is in lawful possession or control of the property designated or has the authority to act in the owner(s), tenant(s). and/or occupants(s) behalf and in their absence. Signature: Nombre: Direccion: Date: --� 12— S-/ zZ PERMISO PARA INSPECCIONAR PROPIEDAD PRIVADA Telefono: FAVOR DE INDICAR: INQUILINO PROPIETARIO Por este medio usted da permiso a (el) O a (los) inspector(es) de Division de Cumpliminetos del Codigo de la Ciudad de La Quinta pars entrar a esta propiedad para inspeccionar todas las areas de la propiedad incluyendo los exteriores de todos los edificios, y/o interiores. Tambien incluyendo la grabacion de audio y video Como se requiere pars determiner si dicha propiedad esta en acuerdo con las leyes del codigo local y estatales. Por este medio de este documento usted declara que tiene posesion legal, o tiene la autoridad o consentimiento del propietario(s), y/o ocupante(s) en su ausencia. Firma: _ Fecha�