STATEMENT OF INTENT TO EMPLOY A MINOR AND REQUEST FOR WORK PERMIT– CERTIFICATE OF AGE
CDE B1-1 (Rev. 07-10)
A “STATEMENT OF INTENT TO EMPLOY A MINOR AND REQUEST FOR WORK PERMIT–CERTIFICATE OF AGE” form
(CDE B1-1) shall be completed in accordance with California Education Code 49162 and 49163 as notification of intent to employ a minor. This form is also a Certificate of Age pursuant to California Education Code 49114.
(Print Information)
Minor’s Information								
								
Minor’s Name (First and Last)	Home Phone							
Birth Date	Social Security Number			Grade			Age	
Home Address	City						Zip Code	
School Information								
								
School Name	School Phone							
School Address	City						Zip Code	
To be filled in and signed by employer. (Please review the General Summary of Minors’ Work Regulations on reverse.)	

Business Name or Agency of Placement	Business Phone		Supervisor’s Name	
Business Address	City						Zip Code	
Describe nature of work to be performed: 									

In compliance with California labor laws, this employee is covered by worker’s compensation insurance. This business does not discriminate unlawfully on the basis of race, ethnic background, religion, sex, sexual orientation, color, national origin, ancestry, age, physical handicap, or medical condition. I hereby certify that, to the best of my knowledge, the information herein is correct and true.

Employer’s Name (Print First and Last)	Employer’s Signature		Date	
To be filled in and signed by parent or legal guardian				
This minor is being employed at the place of work described with my full knowledge and consent. I hereby certify that to the best of my knowledge and belief, the information herein is correct and true. I request that a work permit be issued.

Parent or Legal Guardian’s Name (Print First and Last)		Parent or Legal Guardian’s Signature		Date	

For authorized work permit issuer use ONLY	
Maximum number of hours of employment when school is in session:	
Mon		Tue		Wed		Thu	Fri		Sat		Sun		
Total	

Proof of Minor’s Age (Evidence Type)			Check Permit Type:
*Full-time
**Workability
Restricted General	
***Work Experience Education, Vocational Education, or Personal Attendant	
Verifying Authority’s Name and Title (Pr	int)				
Verifying Authority’s Signature					

*EC 49130 | **Permit Type defined by local school |***Special Education Grant
Copy–District or County Superintendent; Employer; Parent or Legal Guardian	(Over)

STATEMENT OF INTENT TO EMPLOY A MINOR AND REQUEST FOR WORK PERMIT— CERTIFICATE OF AGE
CDE B1-1 (Rev. 07-10)
General Summary of Minors’ Work Regulations
FLSA-Federal Labor Standards Act, CDE-California Department of Education, EC-California Education Code, LC-California Labor Code, CFR-California Federal Regulations

If federal laws, state laws, and school district policies conflict, the more restrictive law (the one most protective of the minor) prevails. (FLSA)
Employers of minors required to attend school must complete a “Statement of Intent to Employ a Minor and Request for Work Permit” (CDE B1-1) for the school attendance for each such minor. (EC 49162)
Employers must retain a “Permit to Employ and Work” (CDE B1-4) for each such minor. (EC 49161)
Work permits (CDE B1-4) must be retained for three years and be available for inspection by sanctioned authorities at all times. (EC 49164)
A work permit (CDE B1-4) must be revoked whenever the issuing authority determines the employment is illegal or is impairing the health or education of the minor. (EC 49164)	A day of rest from work is required in every seven days, and shall not exceed six days in seven.
(LC 551, 552)
Minors under the age of 18 may not work in environments declared hazardous or dangerous for young workers, examples listed below: (LC 1294.1 and 1294.5, 29 CFR 570 Subpart E)
Explosive exposure
Motor vehicle driving/outside helper
Roofing
Logging and sawmilling
Power-driven woodworking machines
Radiation exposure
Power-driven hoists/forklifts
Power-driven metal forming, punching, and shearing machines
Power saws and shears
Power-driving meat slicing/processing machines	
HOURS OF WORK

16 & 17 Year Olds
Must have completed 7th grade to work while school is in session.
(EC 49112)	14 & 15 Year Olds
Must have completed 7th grade to work while school is in session
(EC 49112)	12 & 13 Year Olds
Labor laws generally prohibit non-farm employment of children younger than 14. Special rules apply to agricultural work, domestic work, and the entertainment industry. (LC 1285–1312)	
School In Session

4 hours per day on any schoolday (EC 49112; 49116; LC 1391)
8 hours on any non-schoolday or on any day preceding a non-schoolday.
(EC 49112; LC 1391)
48 hours per week (LC 1391)
WEE students & personal attendants may work more than 4 hours on a schoolday, but never more than 8. (EC 49116; LC 1391, 1392)	3 hours per schoolday outside of school hours (EC 49112, 49116; LC 1391)
8 hours on any non-schoolday
No more than 18 hours per week (EC 49116; LC 1391)
WEE students may work during school hours & up to 23 hours per week.
(EC 49116; LC 1391)	2 hours per schoolday and a maximum of 4 hours per week.
(EC 49112)	
School Not In Session
8 hours per day (LC 1391, 1392)
48 hours per week (LC 1391)	8 hours per day (LC 1391, 1392)
40 hours per week (LC 1391)	8 hours per day (LC 1391, 1392)
40 hours per week (LC 1391)	
Spread of Hours

5 a.m.–10 p.m. However, until 12:30
a.m. on any evening preceding a non- schoolday (LC 1391)
WEE students, with permission, until 12:30 a.m. on any day (LC 1391.1)
Messengers: 6 a.m.–9 p.m.	7 a.m.–7 p.m., except that from June 1 through Labor Day, until 9 p.m.
(LC 1391)	7 a.m.–7 p.m., except that from
June 1 through Labor Day, until 9 p.m. (LC 1391)	
For more information about child labor laws, contact the U.S. Department of Labor at http://www.dol.gov/, and the State of California Department of Industrial Relations, Division of Labor Standards Enforcement at http://www.dir.ca.gov/DLSE/dlse.html.