HomeMy WebLinkAboutC.C. 08 CLAIM 92-05 02-18-92HONORABLE MAYOR AND CITY COUNCIL
CITY ATTORNEY
CLAIMANT: RICHARD MOCERI; D/L: 01-14-92; DATE FILED W/CITY:
01-20-92; CLAIM NO: 92-05; CARL WARREN FILE NO: S 66942 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.
JAMEWIG. ROURKE, City Attorney
IG Rjab: D:021192(CL-9205 jab)
Enclosure: Copy of Claim
cc: Carl Warren & Co.
Finance Director
City manager
DAa-,
CONSENT CALENDAR NO. 8
2-18-92
J
FEBRUARY 11, 1991
HONORABLE MAYOR AND CITY COUNCIL
CITY ATTORNEY
CLAIMANT: RICHARD MOCERI; D/L: 01-14-92; DATE FILED W/CITY:
01-20-92; CLAIM NO: 92-05; CARL WARREN FILE NO: S 66942 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.
JAMEWIG. ROURKE, City Attorney
IG Rjab: D:021192(CL-9205 jab)
Enclosure: Copy of Claim
cc: Carl Warren & Co.
Finance Director
City manager
City of Tustin _
fM AGAINST THE CITY OF T" N
(For .ages to Persons or Person. property)
The law provides generally that a claim must be filed 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 THIS FORM, PLEASE TYPE OR USE BLACK INK
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:
1. a. NAME OF CLAIMANT: i s hA��? �Anx� S A*Q i (n0CE-ki'
b. ADDRESS OF CLAIMANT:
d. TELEPHONE NO: "
e. DATE OF BIRTH:.
f. SOCIAL SECURITY 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. Po*" 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 pkm 14 1 10% q a—
•
b. TIME: fW P20'- . co pM
c. PLACE (Exact and specific location) : C, 0 1 L&&% s
PrN Re
d. HOW and under what circumstances did damage or injury occur? Specify
the particular occurrence, event, act or omission you claim caused
the injury or damage (Use additional paper if necessary):
A b; bA k M -t" KE C 5a -f +bA l l I A LA E
itat k -W- L - kAJEAJA `+-hP-PkA k --- bAGk W i rvd, S
e. WHAT particular action by the City, or its employees, caused the
alleged dama inj ury? A-ttDA ! KAO -�-y� S+,�E fi
t bA 1 •c -1•► cr br
of QAk
5. Give a description of the injury, property damage or loss so far known at
the time of this claim. If thei,�e werR no injuries, state "no injuries".
ONS h!LDk�..n� Q.r_A(1 W1�Vc'� S�^�t� C`j ► Aj K(1165
6. Give the name(s) of the City employe (s causing the damage or in
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7. Name and address of any other person injured:
8. Name and address of the owner or any damaged property: RiekA-P-9 N • MOO&
;-3 X S 1*ivA R D Ak 6't,2 Cb2oti•4 CA - Gl 1 '7 ao
9. Damages claimed: a�,� «� a 6'pkja %A -7/4.X l
a. Amount claimed as of the date:
b: Estimated amount of future costs: • $ o S. " EAft`-AJ --FOQ-tlAY
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.
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WARNING: IT IS 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.
� da of �J �N19ay�, at Tustin, California.
Executed this 11— y
DATE FILED:
CIAIT'S SIGNATURE
B1:CLFORM
Revised 4/29/91
.- 7
PIT
5 9`1P PO 4171
*ALL STAR Ga i * .� LA NABRA 621. W. Whti r t e Blvd. #A 90631 213-690-0345
ONTARIO/POMONA * 5521 Holt Blvd., #B 91763 * 714-986-5899
SAM DIEGO * 1845 Morena Bird. 92110 * Accounting 619-275-5842 RIVERSIDE * 570 E. La Cadena St., # F & G 92501 # 714-276-9890
FOUNTAIN VALLEY * 16600 Harbor Blvd. #A 92708 * 714-775-7744 SIGNAL HILL * 2801 E. Pacific Coast Hwy. 90814 * 213-597.8696
HAWTHORNE * 3940 EI Segundo Blvd. 90250 * 213-675-7544 VAN NUYS 14326 Oxnard St. 91401 * 818-902-1511
IRVINE * 51 Auto Center Drive #B6 92714 * 714-855-3707 VENTURA * 4505 Telephone Rd. 93003 * 805-650-7616
AMT. 1 VERIFIED BY
VEHICLE SERIAL YEMAKE b BODY STYLE - CAUSE OF LOSS
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TE COMPLETED CUST Ra ♦ INSTA}LUR : 600FI7100TOR CLAIM • DATE OF LOSS
FOR
OFFICE
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LABOR _
FREIGHT -
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- RELEASE AND AUTHORIZATION TO PAY OTHER THAN INSURED OR CLAIMANT
SUB TOTAL
ass has been replaced to my complete satisfaction and 1 authorize the
diced to ALL STAR GLASS CO. the fuN arrK" t due me under the to., of my policy covering the said autoerabite.- DEDUCTIBLE.
a!o I understand M lar any reason my insurance company does not pay this Bairn I will be responsible for paymerd d same.
TOTAL AMOUNT -� L _
REFERENCE INVOICE •
INSURED
%X I.D. #95-3415468/CA. CONTRACTORS STATE UC. +x429245
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• INVOICE
PUN b0WN WINDOW 'ntMNG
12321 Magnolia Avenue Suite F 4234
RIVERSIDE, CALIFORNIA 92503
(714) 734-6641 .359-0850
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