Please refer to the following form when applying for a work permit. The downloadable version is listed above for your convenience.
Statement of Intent to Employ Minor and Request for Work Permit
Not a work permit Print all information except signatures
A “STATEMENT OF INTENT TO EMPLOY A MINOR AND REQUEST FOR A WORK PERMIT-CERTIFICATE OF AGE” form (CDE Form 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.
For Minor to Complete:
Student ID # ________________________
_____________________________________________________________________________________________________
| Minors name (last name first) |
Social security number |
Date of birth |
Age |
Grade |
_____________________________________________________________________________________________________
| Home address |
City |
ZIP code |
Telephone |
Ukiah High School
School name
1000 Low Gap Rd. Ukiah 95482 (707) 472-5751
Street address City Zip code School telephone
For Employer to Complete (Please review rules for employment of minors on reverse.)
***Student employees must maintain a minimum 2.0 GPA and attend school regularly. Students who are truant, or those who have excessive absences or tardies in any class, risk having their work permit revoked. Ukiah High School will notify employers of any student employee who is at risk of losing the privilege of working.
***Employers have the right to ask for prospective employee grade and attendance history from UHS!!
_____________________________________________________________
Name of business
_____________________________________________________________________________________________________
Street address City Zip code Business telephone
_____________________________________________________________________________________________________
Minor's work duties Hourly wage
Maximum number of hours of employment when school is in session:
| Mon. = |
Tues. = |
Wed. = |
Thurs. = |
Fri. = |
Sat. = |
Sun. = |
Weekly = |
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.
_____________________________________________________________________________________________________
| Supervisor's signature |
Supervisor's name (print or type) |
For Parent or Guardian to Complete:
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, the information herein is correct and true. I request that a work permit be issued. I understand that this permit may be revoked if grade or attendance requirements are not maintained.
In addition to this employer, my child is working for:
_________________________________________________________
Name of business
_____________________________________________________________________________________________________
| Signature of parent or legal guardian |
Date |
For School to Complete
| Evidence of minor's age: Aeries School Records |
Type: (Circle one) |
Regular
Vacation
Work Experience Education
|
Robert Dieffenbach
Work Experience Coordinator
|
|
Other (specify)
|
______________________________________________________________________________________
| Signature of verifying authority or designee: |
Date |
Modified CALIFORNIA DEPARTMENT OF EDUCATION FORM 1311 (revised 6/7/17)
Back Page of the Permit
| STATE OF CALIFORNIA |
DEPARTMENT OF EDUCATION |
STATEMENT OF INTENT TO EMPLOY A MINOR AND REQUEST FOR WORK PERMIT - CERTIFICATE OF AGE
CDE Form B1-1 (Rev. 07-10)
General Summary of Minors' Work Regulations
FLSA - Federal Labor Standards Act, COE - California Department of Education, EC - California Education Code, LC - California Labor Code, CFR - Califomia 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 lntent to Employ a Minor and Request for Work Permit" (CDE Bl-l) for the school attendance for each such minor. (EC 49162)
- Employers must retain a "Permit to Employ and Work" (COE Bl-4) for each such minor. (EC 49161)
- Work permits (CDE Bl-4) must be retained for three years and be available for inspection by sanctioned authorities at all times. (EC 49164)
- A Work permit (CDE Bl-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 |
14 & 15 Year Olds |
12 & 13 Year Olds |
| Must have completed 7th grade to work while school is in session (EC49112) |
Must have completed 7th grade to work while school is in session (EC49112) |
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. (EC49112)
|
School Not In Session
- 8 hours per day (LC 1391, 1392)
- 48 Hours per week (LC1391)
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- 8 hours per day (LC 1391, 1392)
- 40 hours per week (LC 1391)
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- 8 hours per day (LC 1391, 1392)
- 40 hours per week (LC 1391)
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Spread Of Hours
- 5:00 am - 10:00 pm. However, until 12:30 on any evening preceding a non-schoolday (LC 1391)
- WEE students, with permission, until 12:30 a.m. on any day (LC 1391.l)
- Messengers: 6:00 am - 9:00 pm
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- 7 am - 7 pm except that from June 1 through Labor Day, until 9 pm (LC 1391)
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- 7 am - 7 pm except that from June 1 through Labor Day, until 9 pm (LC 1391)
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