Application for Exemption From Provisions of the Industrial Welfare Commission Order (DLSE 104)

Summary

Application for Exemption From Provisions of the Industrial Welfare Commission Order (DLSE 104)

Text

STATE OF CALIFORNIA 
DEPARTMENT OF INDUSTRIAL RELATIONS  
DIVISION OF LABOR STANDARDS ENFORCEMENT
Return completed form to: 
DIR/DLSE 
– IWC Exemptions  
P.O. Box 420603 
San Francisco, CA  94142 
 
APPLICATION FOR EXEMPTION  
FROM PROVISIONS OF THE INDUSTRIAL WELFARE COMMISSION ORDER  
Please complete the information requested below and return the original form and one (1) copy to the above address. 
Requester’s name:   
Individual/Firm name 
Address: 
Street 
, CA 
 City Zip Code 
Request exemption from Industrial Welfare Commissioner Order No. , Section(s) 
and provide the following information in support of this request: 
• Type of Business: 
• Total Number of Employees: 
•
 Number of employees for whom exemption is requested: 
•
 Occupation(s) for which exemption is requested: 
•
 Length of period for exemption: 
• Explain nature of exemption and provide in detail the necessity for exemption which must include: 
• How the exemption will not materially affect the welfare or comfort of the employees; and, 
• How it will work an undue hardship on business, if not approved. 
Dated: 
Requester Name (printed) and Title or Position
 NEW
 Renewal Signature of Requester 
POST IN CONSPICUOUS PLACE 
(Remove When Permit for Exemption is Received) 
DLSE Form 104  (REV 7/16)

Retrieval chunks

• #1

  STATE OF CALIFORNIA DEPARTMENT OF INDUSTRIAL RELATIONS DIVISION OF LABOR STANDARDS ENFORCEMENT Return completed form to: DIR/DLSE – IWC Exemptions P.O. Box 420603 San Francisco, CA 94142 APPLICATION FOR EXEMPTION FROM PROVISIONS OF THE INDUSTRIAL WELFARE COMMISSION ORDER Please complete the information requ…