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HOME OCCUPATION OF A BUSINESS
PERMIT#Ir � rVVUINSPECTION DATE-3 ��2-;,, TIME //*.O I)l
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
Appimant Names:
Pry-A-v-�-o 4;clutcal
Address:
.777015 Cq .e kwo bq Lci 6?60 cA C A 3
Phone: Email:
-760 '401(6`] -C�Ie(50 DiLl ct c Ma�`�, •C dw�
Type of residence: Square Footage:
k-VIC le sa e q�o sq FT
Type of Business:
--C 't \ e
S-6lii and ( ejf oy-e
isrier uescrfption of the Business Operation: l
/j!o t ,Le„ �i . / Gil Pit n rr ry r u Po n� ?' /YZ
I_acation nd Square Footage of Business in Home: {Ex. Bedroom 120 SF}
19-0 S F
Number of Persons Involved in Business:
nVAe
Description of Machinery, Equipment, and Supplies Being Used: ru S h Mu �wi he
Pali 5 10 Ma LV%, "e, A h 9le 6iv-anciijts , -5hopVQ C
cal �►� lime I m vefs •-�` cleaners +fie reserS S S Iers l
C,0�
I HAVE READ, UNDERSTAND, AND AGREE WITH THE ATTACHED CONDITIONS WHICH A HOME
OCCUPATION PERMIT IS ALLOWED.
APPLICANT SIGNATURE DATE
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 com fete and sign a declaration that states the
following:
I hereby affirm under penalty of perjury, one of the following declarations:
0 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, I will provide the City with a policy or certificate copy within
ten( 0) days of the change in requirements.
APPLYCANT 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.
CONSENT TO INSPECT PRIVATE PROPERTY
Name: Telephone Number:
Property Address:
PLEASE INDICATE IF YOU ARE: �. TENANT PROPERTY OWNER
The undersigned herein consents to the City of La Quinta, Code Compliance Division Inspector(s) 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 or not 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: Date:
PERMISO PARA INSPECCIONAR PROPIEDAD PRIVADA
Hombre: Telefono:
Direccion: �-7(ra L[ l (0 ti Yyt_'\ i i
FAVOR DE INDICAR: _INQUILINO APROPIETARIO
Por este medio usted da permiso a (el) 0 a (los) inspector(es) de Division de Cumpliminetos del Codigo de la
Ciudad de La Quinta para entrar a esta propiedad para inpeccionar todas las areas de la propieda incluyendo
los exteriores de todos los edificios, y/o interiores. Tambien incluyendo la grabacion de audio y video como se
requiere para determinar 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: ,' f I Fecha: