Application for Extension of Minor's Work Hours in Agricultural Packing Plants (DLSE 104-1)

Summary

Application for Extension of Minor's Work Hours in Agricultural Packing Plants (DLSE 104-1)

Text

STATE OF CALIFORNIA 
DEPARTMENT OF INDUSTRIAL RELATIONS  
DIVISION OF LABOR STANDARDS ENFORCEMENT
Return completed form to: 
DIR/DLSE – Minors 
Permit 
P.O. Box 420603 
San Francisco, CA  94142 
 
APPLICATION FOR EXTENSION OF MINOR’S WORK HOURS  
IN AGRICULTURAL PACKING PLANTS  
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 that minors 16 and/or 17  years of age can work up to ten (10) hours per day and provide the following information in support 
of this request: 
• Number of employees for whom exemption is requested: 
• Dates for which extens ion is requested:   From:    To:  
(mm/dd/yyyy) (mm/dd/yyyy 
Describe the work activities the minors will be expected to perform: 
Explain how the work to be performed will not materially affect the welfare or safety of the minor: 
Explain 
how the exemption, if not approved, will work an undue hardship on business: 
I (We) certify to the following: 
•  That the dates requested for the extension of minors’ work hours occur exclusively during the peak hours season for the
 crop(s); 
•  That minors work duties during the extended work hours shall be limited to work upon or directly related to 
aforementioned c
rop(s); 
•  That minors shall only work the extended hours on days when school for the minors’ school district is not in session; and, 
That all informatio
n contained in this application is true and correct.  It is understood that any falsity in or abrogation of 
statements contained herein are grounds for the immediate revocation of the extension and will subject all responsible 
parties to all civil and criminal penalties arising from the violation of child labor laws that would result if no extension had 
been granted by the Labor Commissioner. 
Dated: 
Requester Name (printed) and Title or Position 
Signature of Requester 
POST IN CONSPICUOUS PLACE 
(Remove When Permit for Exemption is Received) 
DLSE Form 104-1  (REV 7/16)

Retrieval chunks

• #1

  STATE OF CALIFORNIA DEPARTMENT OF INDUSTRIAL RELATIONS DIVISION OF LABOR STANDARDS ENFORCEMENT Return completed form to: DIR/DLSE – Minors Permit P.O. Box 420603 San Francisco, CA 94142 APPLICATION FOR EXTENSION OF MINOR’S WORK HOURS IN AGRICULTURAL PACKING PLANTS Please complete the information requested b…