DeNovita Qw�ra
CALIFOKNIA
HOME ()CCUPATION OF A BUSINESS
PERMIT# H02023-0020 5/4/2023 3:30 P.M.
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 $117.00 LOCATION CHANGE $57.00
Applicant Names:
Address:
5-�
t
Phone: ma I:
-7 77- 3) 3 o
Type of residence: Square Footage:
I )0
Type of Business:
Brief Descri on of the Business Operation:
I on Y, I\]a-e, + t i eot 611444e-s-
Location and Squdre Footage of Business in Horne: (Ex. 6e& om 120 SF)
s
Number of Perso s I olved in Business:
Description of Mac finery, Equipment, and Supplies Being Used: ��
I HAVE READ, UNDERSTAND, AND AGREE WITH THE ATTACHED CONDITIONS WHICH A HOME
OCCUPATION PERMIT IS ALLOWED.
AP LI NT SIGNATURE DATE
IZ573
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 cQmplete and sign a declarationh
follgwing;
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 bell provide subject t e City wi h a policy orpensation cert'fcate copy provisions
wi h of
Section 3700, I w
ten(10) days of the change in requirements.
APPL CANT SIGNATURE DATE
�; 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.
IF APPLICANT IS OTHER THAN THE PROPERTY OWNER A SIGNE❑ AUTHORIZATION FROM
OWNER OR RENTAL/LEASING AGENT IS REQUIRED.
f C��
O NE AGENT SIGNATURE 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
APPROVED_
I HAVE READ AND UNDERSTAND THIS
STATEMENT.
SIGNATURE
CODE COMPLIANCE USE ONLY
DENIED
OFFICER
SPECIAL CONDITIONS
5-Lf — Zo 2
DATE