Self Haul Certification FormSELF-HAULING CERTIFICATION
REV 4/03/2018
Building Permit Applicant: Phone: ( _)
(Please Print)
Demolition Contractor: Phone: ( _)
(Please Print)
Project Address:_____________________________________________ Permit # _________________
(Please Print)
Mailing Address:
(Please Print)
CERTIFICATION
As the project contractor, I certify under penalty of perjury that I have read and understand the attached
requirements and general conditions, and shall comply with all City requirements for transport and recycling
construction debris and for reporting compliance with the current Building Code. I understand I am responsible
for compliance with City of Cypress Municipal Code Chapter 12 Article 8 Section 27-38 and that my failure to
comply with any portion will invalidate my self-haul certification. (Self-Haul Fee applies)
Contractor Signature Date
Verification Information (to be filled out by City)
Truck Driver California Drivers License Expires:
Contractor owns leases vehicle. Vehicle has been inspected and meets all applicable
requirements. Vehicle lease agreement allows contractor to use vehicle for self-hauling
construction debris.
Vehicle registration. Expires:
Vehicle registration. Expires:
Vehicle registration. Expires:
Vehicle registration. Expires:
Certificate of Insurance. Expires:
Contractor will have containers on project site to store construction debris (Public Works
Encroachment Permit required for containers placed in the public right-of-way)
Proof of ownership of construction debris storage containers
Contractor has no outstanding charges due to City or City’s franchised solid waste hauler for
collection services previously received at project address.
The City reserves the right to prohibit contractor from self-hauling for violation of any
condition set forth in this certification form.
Self-Haul Certification Requirements
1. A Certification for Self-Haul accompanied with an administrative fee of $255 or fee adopted by
resolution of the City Council (CMC 12-32(b)).
(Administrative fee is non-refundable and will not be prorated)
2. Vehicle requirements for hauling construction debris:
a. Vehicle must be operational and meet all applicable Vehicle Code Standards.
b. Hauling capacity of a minimum of 32 gallons of construction debris.
c. Ability to haul waste materials in a safe, sanitary manner so that no material will spill, leak,
drip, blow scatter or fall from vehicle.
d. For vehicles that are not fully enclosed, contractor must produce a tarp or other material that
will be used to completely secure materials being self-hauled.
3. Evidence of valid vehicle registration.
4. Evidence of contractor ownership of vehicle or lease to use vehicle for the hauling construction debris.
5. A valid California driver’s license and proof of vehicle insurance.
6. Provide proof of ownership of available container on property for storage of construction debris.
7. Contractor must be in good standing with City of Cypress and City’s franchised solid waste hauler for
all costs of collection services previously provided.
Self-Haul General Requirements/Conditions
1. Self-haul certification shall be good for the duration of the project.
2. Self-haul certifications must be completed for each project.
3. Contractor shall not:
a. Haul debris to a dumpster/roll-off bin outside of City limits for disposal/processing to avoid the
use of the City’s franchised waste hauler;
b. Utilize the services of another entity to haul away the dumpster/roll-off bin;
c. Rent a dumpster/roll-off bin from any other entity other than the City’s Franchised Hauler.
4. Contractor is responsible for notifying the City of any change in vehicle used for self- hauling, and is
responsible for providing current license, insurance and registration documents on file with the City
for the duration of the project. The City will not provide notification. Failure to provide updated/current
documentation will result in the revocation of self-haul.
5. Contractor must dispose/recycle construction debris weekly at any licensed or permitted landfill or
recycling facility. Contractor shall retain weekly receipts for disposal/recycling of all construction
debris, which shall be submitted to the City at the end of the project pursuant to the City’s Construction
& Demolition Diversion Program.
6. Contractor is liable for any damages and clean-up costs resulting from any solid waste or construction
debris spilling, leaking, dripping, blowing scattering or falling during the course of self-hauling
activities.
7. The Contractor self-hauling shall be subject to revocation if the Contractor violates any provision of
Cypress Municipal Code Chapter 12.