HomeMy WebLinkAboutCC 8 CLAIM #91-23 07-01-91CONSENT CALENDAR NO. 8
AGENDA7-/-//
7-1-91
AT? : JUNE 24, 19 91
TO: HONORABLE MAYOR AND CITY COUNCIL
FR0hri: CITY ATTORNEY
SUBJECT: CLAIMANT: GENE STEWART; D/L: 05-09-91; DATE FILED W/CITY: 05-
15-91; CLAIM NO: 91-23; CARL WARREN FILE NO: S 64416 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.
Very trs
r/4
JAM G. ROURKE
City Attorney
JGR:jab:6-21-91(CL-9123. jab)
Enclosure: Copy of Claim
City of Tustin
1IM AGAINST THE CITY OF T1 IN
(For Damages to Persons or Personal Property)
'he law provides generally that a claim must be filed with the City Clerk of
he 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, 300 Centennial Way, 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:
NAME OF CLAIMA
ADDRESS OF CLA
CITY/ZIP CODE:
TELEPHONE NO:
DATE OF BIRTH:
SOCIAL SECURITY i.v.
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: �'- !EL - cl I
b. TIME: A , d .4 �3• e d AD M
C. PLACE ('Exact and specific location) :
d. HOW and under what circumstances did damage or injury occur? Specify
the particular occurrence, event, act or omission you claim caused
the inlurY ,or damacge (Use additional paper if necessary):
e. WHAT particui action by the City, or employees, caused the
alleged dan}age or injury?
.- u ,C r I r�, :5a T t- 4-�" s
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
inj ur es" .
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 pf the owner or any df maged p operty:
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 mounts clamed (include copies of
all bills, invoices, estimates,.etc.
10. Names and addresses of all witnesses, hospitals, doctors, etc.
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
DATE FILED:
CLAIMANT'S`SIGNATURE
B1:CLFORM
Revised 10/23/90
, 19 , at Tustin, California.
OF REPAIRS GUARANTY CHEVROLET ;EO
711 East 17th Street a P.O. Box
FCHEVlq0t11 SANTA ANA, CA 92711
(714) 973-1711
` DATE
Address �? Zip9=°
C NT
Phone l Mlles 0/
21C 3
IN, .D
�� V Ll Color License K ( � VIN M
Year & Make - -
Insurance Co.
Address Phone
Policy # Ded. mt. Date of Loss Claim # Co. Adjustor
A ,.
Eng Trans Cruise
Tilt A1CRadio
Body PARTS MISC. Meeh.
REPLACE REPAIR ESTIMATE OF REPAIR COSTS1.
LaborHrs Labor HR
A,
1
Z7
cp- I I I
/
21
-a2
. I
I I
I
i l
PARTS PRICES BASED ON STANDARD CATALOGUE PROCUREMENT PRICE LISTS SUBJECT TO CHANGE WITHOUT NOTICE.
BASD ON OUR INSPECTON AND ES NOT COVEROR
LABOR
NAL
WHICH MTHE AY E REQUIRED AFTERE IS AN ESTIMATES HE WORK HAS B EIN OPENED U P. BECAUSE OF THIS. TOHE ABOVE PRICES ARE I I p
NOT GUARANTEED. BODY LABOR
ESTIMATED BY — TOTAL PARTS j
"I autnonze the following repair work to be done along with the necessary parts and material and grant permission Io operate the vehicle harem described for the PwPose TOTAL M 1 SC.
d I*sling and l of Inspection. vnth my own fuel. You will not be held responsoble for loss or damage to vehicle or anKNs lett in vehicle on use Of bre. lheh. acco0e n or any
other Cause bo gond your, Control. I urnderstand that cash payment in full amount of repair *row total is required for release of vehicle unoess doer hemo
arrangements an maw
be added
a I
al time ol write up. An express mechanics ben is acknowledged on the vehicle to secure taunt of repairs. I agree that $age orcharge of S&OO Per day M E C H. L A B O R
Io my frit Sher 4d hours from repair order Closing by Service Cashier."
we repair, strai htrn, and replace pans .nth used merchandise. The unders+gned hereby acknowledges this practice and agrees
when requested by insurance companies g SALES TAX ^
;O same as approved estimate so state!. Indust Tome Alk wanes Or Own axPenenCe
,ges for Labs are not based on actual time, but are establ;shed by mullrplyinq our Retail Labor Rate d $45.00 per hour by ry
age Time Required.✓ 7� `
inaf or dittersom reostm am required: you will be contacted for your advance approval. ESTIMATE TOTAL
nave arty questions. Please contact our Body Shop Manages. I
1 hereby acknowledge responsibility for the entire amount of repair. I undemund that pans i workmanship are guaranteed for 90 days or 4.000 "We (whichever ADVANCE CHARGES
occurs first.) The dealer is not responsible for unevellsblllty of pans or decays In pans shipments beyond dealer's control.
GRAND TOTAL
CUS'TOMER'S SIGNATURE AND
ACKNOWLEDGEMENT OF COPY
JT M0. 63980
(
JW PRINTING CO.. INC. CALL 813) 387-72 31
S
I
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(
JW PRINTING CO.. INC. CALL 813) 387-72 31