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'f ORNIA - CITY OF LA QUINTA
DESIGN & DEVELOPMENT DEPARTMENT
HOME OCCUPATION OF A BUSINESS
PERMIT#� INSPECTION DATE 61q6l') 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:
Jerry Roisentul
Address:
79939 Castille Drive
Phone: Email:
760-272-0296 Serry@championmentorship.com
Type of residence: Square Footage:
Sinqle Family 2,000
Type of Business:
Leadership Coaching and Training
Brief Description of the Business Operation:
Do zoom trainings with clients all over the world helping them in developing their leadership skills.
Location and Square Footage of Business In Home: (Ex. Bedroom 120 SF)
Side Room ... 150 sq ft
Number of Persons Involved in Business:
1
Description of Machinery, Equipment, and Supplies Being Used:
None
I HAVE READ, UNDERSTAND, AND AGREE WITH THE ATTACHED CONDITIONS WHICH A HOME
OCCUPATION PE ALLOWED.
APPLI T S G'NATURE DATE
IF APPIAC19NT IS OTHER THAN THE PROPERTY OWNER, A SIGNED AUTHORIZATION FRC
OWNER RENTALILEASING AGENT IS REQUIRED.
GtA1Z;�__ -
6W NER/AGE Tl/llNATURE
AGENT COMPANY NAME 0
��;w
DATE
-74a - 66 7r'
CONTACT PHONE 7
PLEASE CONTACT YOUR HOMEOWNER'S ASSOCIATION PRIOR TO PAYING FOR YOUR HC
OCCUPATION PERMIT. YOUR HOA MAY RESTRICT OR PROHIBIT A HOME -BASED BUSINE
IMPORTANT: FALSE OR MISLEADING INFORMATION SHALL BE GROUNDS FOR DENYIN(
YOUR APPLICATION; FAILURE TO COMPLY WITH THE CONDITIONS LISTED ON THI
ATTACHED PAGE SHALL BE GROUNDS FOR REVOCATION OF THIS PERMIT
F
CODE COMPLIANCE USE ONLY
CS
APPROVED. E SPECIAL CONDITIONS
OFFICER 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 complete and sign.,a declaration that states the
following:
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.
l� 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( ) days of th ge in requirements.
APPLTCANT$I,0NATURE
fl,�L
DATE
WARNING; Failure to secure Worker's Compensation coverage is unlawful and shall
subject an employer to criminal penalties and civil fines up to $1o0,000. 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.