HomeMy WebLinkAboutCC 3 CLAIM #90-18 07-16-90DATE:
TO:
FROM:
SUBJECT:
July 3, 1990
HONORABLE MAYOR AND CITY COUNCIL
CITY ATTORNEY
CONSENT CALENDAR NO. 3
7-16-90
Inter - Com
CLAIMANT: Tustin Paint Mart; D/L: 6/2/90; DATE FILED
W/CITY: 6/5/90; CLAIM NO: 90-18; CARL WARREN FILE NO:
S63467PRL
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.
J E OURKE
City Attorney
JGR:kbg(F4)
Enclosure: Copy of Claim
-_•ut111'1 t-iL7ty1 1V :7 1 111 L' �. 1 1 1 kJ L' t v v 1 1 �+ , � t
V4(For Damages to Person or Personal Property)
Received by Lu ,=OV'� r.�--7-iGC _ via JUN 5 1990
U.S. Mail
T1 ` ,r -off ice Mail
C the Counter OFFICE-TUSTIN CITY CLERK
The aw provides generally that a claim must be ilea with the City Clerk o
the City of Tustin within 100 days after which 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 informa
tion by paragraph number. Completed claims must be mailed or delivered to tr
CitClerk, TheCity of Tustin, 300 Centennial Way, Tustin, California 9268
Y
TO THE HONORABLE MAYOR AND CITY COUNCIL, City of Tustin, California:
The undersigned respectfully •submits the followingclaim and information rela
tive to damage to persons and/or personal property:
/)
1. NAME OF C
LAI MANT : C // _S i0 /L�I
a. ADDRESS OF CLAIMA T: -�
b. PHONE NO:
C. DATE OF BIRTH:
(�7/�� ) �F'� �'"� �) �- � DRIVERS
SOCIAL
d. SECURITY NO: e. LICENSE NO:
2. Name, telephone and post office address to which claimant desires notices
to be sent, if other than above:
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 employees) of the
City of Tustin only:
4. Occurrence or eveXtrom which the claim arises:
b, "TIME: 4;,
/c. PLACE (Exact
a. DATE:�,� :? C� - f P
and speci i location):
d. Flow and under what circumstances did damage or injury occur? Specify
the particular occurrence, event, act or omission you claim ca
the-injury or damage ( se additional,'P.aper if `essary) .
e. W particular articular action by the City, or its employees, caused the
all ged amage�or.
injury?� � /
- G�_ve a description o" .',e injury, property dama or loss so
far as is
"no
known at the time of z. claim. If there were r in ries,
inju- e l�i4
state
C,�C
.;
6. Give the name (�s) of the Cit employee (s r causing the damage or injury:
7. Nam and address of any other person injured:
8. a ress of the owner of any damaged property: Alz
=Nam4"nd
9. Damages claimed: O
Amount claimed as of this date:
a. C>
b. Estimated amount of future costs:
c. Total amount claimed:
for of amounts claime t:(iTc(�l=ud�ec�opi�eso
allbil s,
d. Basis computation
invoices, estimates, etc.:
10.
Names
c
a.
b.
c. _
d.
and addresses of a'1 witnesses, hcyspitals.. docto etc.:
11. any add,i ioal infR mation that might be helpful in considering this claim:
WARNING: IT IS A CRIMINAL OFFENSE TO FILE A FALSE CLAIP'I! ( Penal Code
Section 72; Insurance Code Section 556.0)
I have read the matters and statements made in the above claim and I know
bee
same to be true of my own knowledge, excpt as matter� Ihose believematters the same to be true
upon information or belief and as to such
I certify under penalty of perjury that the foregoing is TRUE AND CORRECT.
i (fes
Executed this day of J--" 'v 19 at Tustin, California.
r.
office of the City Clerk,
Tustin, California
CL NO:
Revised 8/05/81
JGR:se:R:8/5/81 (A)
WA
P`.
CLAIMANT ' S/f SIGNAT URE
DATE FILED:
DIAMOND GLAC invoice
1219 SOUTH MAIN STREET
SANTA ANA, CALIF. 92707
Bus. 542-5798 - 542-4897
• r S
S H
O I
L p
O p
E
D
-ro TO •
DATE Y
OUR OCL2fjL=--
C►ATE SHIPPED
OUANTI TY DESCRIPTION
PRICE AMOUNT
a
C ILIE K.
TUSTIN PAINT MART
7Z0 WEST FIRST ST.
TI ISTIN. CA 92660
( 714) 838-8271
r
L'A6 _
Qn��N PAINTS
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