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Home My WebLink AboutCC 12 CLAIM #93-08 04-05-93!� G E N D A_�—�� CONSENT CALENDAR N0. 12 4-5-93 Inter -Com DATE: MARCH 30, 1993 TO: HONORABLE MAYOR AND CITY COUNCIL FROM: CITY ATTORNEY SUBJECT: CLAIMANT:CHI; CLAIM NO: 3FILE DATE FILED 02-17 93 CARL WARRENA NO: S0740289 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. 1GR:jeb:033093(CL9308.j+b) Enclosure: Copy of Claim cc: Carl Warren & Co. Finance Director City Manager JAM4GROWURKE, City Attorney City of Tustin C1 I AGAINST THE CITY OF TUL (For Damayas to Persons or Personal _.operty) 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 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: / 1. a. NAME OF CLAIMANT: IOUC ja Ch01 b. ADDRESS OF CLAIMANT: c. CITY/ZIP CODE: d. TELEPHONE NO: e. DATE OF BIRTH:' 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. _X The City of Tustin only. b. The following employee(s) of the City of Tustin only: C. The City of Tustin_ and the following employees) of the City of Tustin only:. 4. Occurrence or event from which the claim arises: a. DATE: 70.n 1 g I AQ3 b. TIME: 0.rOun 5 • 60 AM . C. PLACE (Exact and specific location): /57/2 19asadena Ave j„ s=>7 C d. HOW and under what circumstances did damage o injury occur? Specify the particular occurrence, event, act or omission you claim causec the /injury or damage (Use additional paper if necessary): �— �%A2 K ' C. WHAT particular ;tion by the City, or i employees, caused the alleaed damage t 2in-iury? 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". o 6. Give the name(s) of the City employee(s) causing the damage or injury: 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: zt:3: / d. Attach basis for computation of amounts claimed (include copies of all bills, invoices, estimates, etc. 10. Namesand addresses o]f all witnesses, 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. Executed this day of_T 19 93 at Tustin, California. DATE FILED: CLAIb 'S S�GNATURE B1:CLFORM Revised 4/29/91 TUSTIN POLICE DEPART" TODAY'S DATE NAME OF PERSON NV/O/LVED TYPE OF REPORT LOCATION OF INCIDENT APPLICATION PU3LIC DISCLOSURE CASE NUMBER v l C `7- �cuh �d n ^ � DATE OCCURRED r ._ 19 1-7;5 i acip>,a lT�� ( 11c.,h2.na�5 REQUESTOR' S FULL NAME Jnnc, BIRTH DATE / VRIVERS LICENSE # STATE HOME ADDRESS //� BUSINESS ADDRESS HOME PHONE # ')/;= BUSINESS PHONE # IF FIRM REPRESENTATIVE, GIVE BUSINESS NAME (Firm representatives need not fill out home address and home phone number, all other information is mandatory.) MARK BELOW YOUR AUTHORITY SECTION FOR THIS INFORMATION VICTIM SUSPECT L,-/ WITNESS AUTHORIZED REPRESENTATIVE/LIST TYPE OTHER/EXPLAIN REASON FOR THIS REQUEST DISSEMINATION OF ANY POLICE RECORDS INFORMATION TO ANY UNAUTHORIZED PERSONS IS PROHIBITED AND IS PUNISHABLE AS A CRIME UNDER STATE LAIC. -----------------------DO NOT WRITE BELOW THIS LINE ------------------------ APPLICATION RECEIVED BY TYPE OF ID SHOWN (Attach photo copy of ID VERIFIED & COPY ATTACHED BY ID here) APPLICATION & REPORT PROCESSED BY AMOUNT DUE $ PAID PAYMENT RECEIVED BY — �-U,l TO BE PICKED UP TO BE MAILED DATE APPROVED DENIED BY:�� RECORDS INVESTIGATION TRAFFIC SEASON FOANY DELETIONS OR DENIAL: 1- — — � — 'PD #326 (Revised 4/80) Believe in the Lord Jesus, and'you will be saved -you and your household. _ —Acts 16:31— ; 4 -a 24 4 441 1`1 -14 I Val 'T<t+-a- ces740- -AFf'B t_+ 16:31— NAME 6 Anal Auto Body Sh< A ESTIMATE COMPLETE REPAIRS BODY & PAINT 3811 Artesia Ave. -FOREIGN Fullerton, CA 92633 DOMESTIC (714) 523-4741 FIBERGLASS DATE I/ PRESPHOHO NE •MO.RE `zip . / CITY O C GOOF OwYe• INS. CO. .vs a ADJ. PHONE YR, E MAKE MOOEL OCOV ]TYLE LICENSE ..LES SERIAL ADOITIONAL Work OK'd By _.............. _............. TO. .............. ..... ................ (Svc Advisor) MTE ._AAAA _ ._AAAA.. AAAA ... AM Time PM .......................... AMOUNT .... ....... .... ............. AAAA PARTS PRICES Mud on Standard Catalogue, L Price CHARGES WITHOUT NOTICE. Sainte Charges may M added for special nems. not available bully. REPLACED PARTS 'D, unless Owner asks Return of Paris when Order is placed. Above estimate Mud . inspection. Additional Pans, Or tabor, may be required after the work has opened .male Previously obscured. ESTIMATE EXPIRES 30 MTS AFTER DATE. My Car Hill M driven by your employees to make Rrluired tests at my risk. M express m chrinic's lien is hereby acanowledged an above vehicle to seau the amw M of repairs theram. I hereby waiu the Statute of Limitations and if any action on this araum requires employment of an attorney I agree to pay Illz% interest per math. whits is annual parcenble rate of IB% from dale, reasonable attorney's lee and arnt casts. I Mve read the above, received a copy. and above wore hereby authorued (0. ,JAgent) By _. Date ._... ... _. __. _.. INSURANCE DEDUCTIBLE MUST BE All PSR. new, Nnlins ..dad �]�.��! ex,:, (S) Srblet, (EX) Eacnanpa,y NrF1 `� LABOR (U) Used, (R) Rebuilt, atc. OPEN ITEMS PARTS PAINT MAT'L SUBLET NET SALES TAX _ ESTIMATE TOTAL, Adv. Charges TOTAL $ i0 / DescriptionFYwLR-NR LABOR PARTS LIST aPAINT 2 3 4G- 6 / 6 7 . 8 9 10 13 14 15 16 17 1B 21 j20 22 23 t24 F ADOITIONAL Work OK'd By _.............. _............. TO. .............. ..... ................ (Svc Advisor) MTE ._AAAA _ ._AAAA.. AAAA ... AM Time PM .......................... AMOUNT .... ....... .... ............. AAAA PARTS PRICES Mud on Standard Catalogue, L Price CHARGES WITHOUT NOTICE. Sainte Charges may M added for special nems. not available bully. REPLACED PARTS 'D, unless Owner asks Return of Paris when Order is placed. Above estimate Mud . inspection. Additional Pans, Or tabor, may be required after the work has opened .male Previously obscured. ESTIMATE EXPIRES 30 MTS AFTER DATE. My Car Hill M driven by your employees to make Rrluired tests at my risk. M express m chrinic's lien is hereby acanowledged an above vehicle to seau the amw M of repairs theram. I hereby waiu the Statute of Limitations and if any action on this araum requires employment of an attorney I agree to pay Illz% interest per math. whits is annual parcenble rate of IB% from dale, reasonable attorney's lee and arnt casts. I Mve read the above, received a copy. and above wore hereby authorued (0. ,JAgent) By _. Date ._... ... _. __. _.. INSURANCE DEDUCTIBLE MUST BE All PSR. new, Nnlins ..dad �]�.��! ex,:, (S) Srblet, (EX) Eacnanpa,y NrF1 `� LABOR (U) Used, (R) Rebuilt, atc. OPEN ITEMS PARTS PAINT MAT'L SUBLET NET SALES TAX _ ESTIMATE TOTAL, Adv. Charges TOTAL $ i0 Maio: