HomeMy WebLinkAboutC.C. 07 CLAIM 92-2 02-18-92CONSENT CALENDAR NO. 7
2-18-92
AGENDAa-/.
Intel -Com
DATE: JANUARY 30, 1991
TO: HONORABLE MAYOR AND CITY COUNCIL
FROM: CITY ATTORNEY
SUBJECT: CLAIMANT: CAROL TAYLOR; D/L: 01-06-92; DATE FILED W/CITY: 01-
07-92; CLAIM NO: 92-2; CARL WARREN FILE NO: 8 66923 PRL
After investigation and review it is recommended that the
above -referenced claim be rejected and the City Clerk directed to
give proper notice of the rejection to the claimant and to the
claimant's attorney.
JAMES G. ROU KE, City Attorney
JGR: jab:013092(CL-9202.jab)
Enclosure: Copy of Claim
cc: Carl Warren & Co.
Finance Director
City Manager
City of Tustin
IM AGAINST THE CITY OF TD N
(For D -;es to Persons or Persona_ ,:operty)
The law provides generally that a claim must be f iled with the City Clerk of
the City of Tustin within 6 months after the incident or event occurred. Be
sure your claim is against the City of Tustin, not another public entity.
Where space is insufficient, please use additional paper and identify
information by paragraph number. Completed claims must be mailed or
delivered to the City Clerk, City of Tustin, 15222 Del Amo Avenue, Tustin,
California 92680
WHEN COMPLETING TRIS FORM, PLEASE TYPE OR USE BLACK INR
TO THE HONORABLE MAYOR AND CITY COUNCIL, City of Tustin, California:
The undersigned respectfully submits the following claim and information
relative to damage to person and/or property:
NAME OF CLAIMANT:
ADDRESS OF CLAIMANT:
CITY/ZIP CODE:
TELEPHONE NO:
DATE OF BIRTH: Io
SOCIAL SECURITY NO:
DRIVERS LICENSE NO:
2. Name, telephone and post. office address to which claimant desires notices
to be sent ( if other than above) :
3. This claim is submitted against:
a. ✓ The City of Tustin only.
b. The following employee(s) of the City of Tustin only:
C. The City of Tustin and the following employee(s) of the City
of Tustin only:
4. Occurrence or event from which the claim arises:
a. DATE: J aVA L4 a r �:
b. TIME • A7 POro y., t O
C. PLACE (Exact and =ivlo
is location): Y -IV
�P � ;ro Yin E 1 P 1 u.za.
d. HOW and under what circumstances did damage or injury occur? Specify
the particular occurrence, event, act or omission you claim caused
the in-ury,or damage (Use additional paper if necessary):
S - T
,� rr -- ,^S
o Y SCC
L r o
e. WHAT particular ---action by the City, or it-,\ employees, caused the
alleged damac injury?
5. Give a description of the injury, property damage or loss so far known at
the time of this claim. If there were no injuries, state "no injuries".
iCA k1 r -h 1Yv h i'No d, rn CC
1A%r7 I✓11 to 1PC.
6. Give the name(s) of the City employee(s) causing the damage or injury:
�F)PS vtZ--CAA0 LU
7. Name and address of any other person injured:
8. Name and address of the owner or any damaged property:
9. Damages claimed:
a. Amount claimed as of the date:
b. Estimated amount of future costs: --
c. Total amount claimed:
d. Attach basis for computation of amounts claimed (include copies of
all bills, invoices, estimates, etc.
10. Names and addresses of all witnesses, hospitals, doctors, etc.
NoVIC �tloujr
WARNING: ITIS A CRIMINAL OFFENSE TO FILE A FALSE CLAIM!!
(Penal Code Section 72; Insurance Code Section 556.0)
I have read the matters and statements made in the above claim and I know the
same to be true of my own knowledge, except as to those matters stated to be
upon information or belief and as to such matters I believe the same to be
true. I certify under penalty or perjury that the foregoing is TRUE AND
CORRECT.
r
Executed this �= day of f , 19at Tustin, California.
DATE FILED: �fl (� �lY 6{ �•
CLAIMANT'S SIGNA E
B1:CLFORM
Revised 4/29/91
OF REPAIRS
--
cu Q )f�
ADORES& � OAT
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AAE OF CAR YEAR
NsuFEO •v
TYPE LICENSK NUMBER
ADJUSTER
MILCACK MOTOR NO. SERIAL NO
?3�f ON It_
INSPECTOR HOME
NOME
--
DESCRIPTION OF REPAIRS AND REPLACEMENTS
q 9 (0c) q •� �
PARTS
LA13OR
AMOUNT
PAINT
AMOUNT
TO -%t.
AMOUfJ)
�� lye
NUMBER
AMOUNT
FS r; ENV
IV / S S Q /V
'\UTO CENTER DR.
IN, CA 92608
,� 669-8282 JAMES VAt�!CURA
FAX 714 669-8280 Parts Consultant
1
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I he ubove Is an estrinote based an our inspection and does not
.uver Ony additional parts or labor which may be required after the
j viak hos been opened up. Occasionally after the work has started,
�,urrt or damaged parts ore discovered which are not evident on the
kv.t In,oectlon. Because of this the above prices are not guaranteed,
..11 .., for oinmeotme occeptance Only.
TOTAL ---- - i
_ 1
3�
TAX ---- - -
TOTAL
ESTIMATE -----L
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ALTERA` N 6 cLZ4,x
CE ZER
TAILORING & ALTERATION SPECIALIST
(714) 838-3182 DRY CLEANING & LAUNDRY
ROSE
610 EI Camino Real Hours:
Tustin, California 92680 Mon. thru Fri: 8:30-6:00
Saturday: 9:00-5:00