HomeMy WebLinkAboutCC 3 CLAIM #89-11 06-19-89· AGEN.
DATE:
1989
CONSENT CALENDAR
NO. 3
6-19-89
Inter-Corn
TO:
FROH:
SUBJECT:
HONORABLE I~YOR AND CITY COUNCIL
CITY ~TTORNEY
CT~,I~: FORREST THATCHER; D/L: 4/18/89~° DATE FILED
W/CITY: 5/10/89; CLAIPi NO: 89-11; CARL WARREN FILE NO.
S57840 PRB
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 rejec'tion to the claimant and to the
claimant' s attorney.
/~_.MES G' ROURKE
City Attorney
JGR(F4. se)
Enclosure: Copy of Claim
,- (For Damages to Persons or Personal Property).
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Received by via
U.S. Mail
Inter-office Mail
-er the Counter
The law provi.des generally that a claim must-be filed with the City Clerk of
the City of Tustin within 100 days after which .the incident or event occurr~
Be sure your claim is against th'e City of Tustin, not another public entity...
Where space is insufficient, please use additional paper and identify inforn
tion by paragraph number. Completed claims must be mailed or delivered to t
Cit~; Clerk, The City of Tustin, 300 Centennial .way, Tustin, California 9268C
TO THE HONORABLE MAYOR AND CITY COUNCIL, City of Tustin, California:
The undersigned respectfully submits the following claim and information re/
tire to damage to persons a~d/or personal property:
NAME OF CLAIMANT: ~_,~~
a. ADDRESS OF gLAIMAN[T: .
c. DATE OF~BIRTH:
SOCIAL DRIVERS
d. SECURITY NO: ~ ~%-~~ e. LICENSE NO:
2. Name, telephone and post office address to which claimant desires notice
to be sent, if o'ther than above:
This claim is submitted against:
The City of Tustin 'only.
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: 4of~-~ b. 'TIME: 7~1~ ~ c. PLACE (Exact
and specific location):
d. How and under what circumstances did damage or injury occur? Specif'.
the particular occurrence, event, act or omission you claim caused
the injury or damage (Use additional paper if necessary).
e. what particular action by the City, or its employees, caused the
alleged damage or injury?
Give a description of t ~'" injury, property dama~- - loss so far as -is~.
known.at the time of tk claim. If there were ~' injuries, state "no
injuries" . ·
Give the name(s) of the City employee(s) causing the damage or injury:
./
Name and address of any other person injured: ~/~
/
. Name and address of the owner of any-damaged property':
Damages claimed:
a." Amount claimed 'as of this date:
b. Estimated amount of future costs:
c. Total amount claimed: '
d. Basis for computation of amounts claimed (include copies of all bills,
invoices, estimates, etc.:
__
]. Names and addresses of all witnesses, hospitals, doctors, etc.:
a.
b.
k~ ' ~~ditional information' that might be helPful in considering t'his claim:
·
kRNING:--'IT IS A CRIMINAL OFFENSE TO FILE A FALSE CLAI;I: (Penal Code · Sedtion 72; Insurance Code Section 556.0)
have read the matters and statements made in the above claim and I know the
~me to be true of my own knowledge, except as to those matters stated to be
)on information or belief and as to such matters I believe the same to be true
certify under ~enalty of perjurY that the foregoing is TRUE AND CORRECT.
(ecu ted this
day-of . ~
, 19 ~ , at Tustin, California.
--fice of the City Clerk,.
~s'- ', ~alifornia
LAIM NO:
.~vised 8/05/81 -
iR:se :R:8/5/81 (A)
CLAIMANT ' S SIGNATURE '
DATE FILED:
NAME
,
ADDRIE_$$
CITY/STATE
1000 WEST PACIFIC COAST HIGHWAY
NEWPORT BEACH, CA 92660
(714) 645-1000
INVOICE
B.A.R. # AD139032
·
D~TE SALESMAN
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PURCHASE ORDER NO. COM. WHSE
ZIP
CAR LICENSE NO. MILEAGE PHONE
SIZE
DESCRIPTION
VALVE STEMS
UNIT
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EXTENSION
MECHANICAL LABOR
Wheel Alignment ..-~ .. -, · , ·
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LABOR TOTAL
~ereby authorize the above repair work to be done along with necessary materials.
,u and your employees may ot3erate above vehicle for purposes of testing, inspection
delivery at my risk. An expr. ess mechanic's lien is acknowledged on above vehicle
secure the amount of repalm thereto. You will not be held responsible for loss or
mage to vehicle or articles left in vehicle in case of fire, theft, accident or any other
use beyond your control.
TIRE LABOR
Wheel Balance
Flat Repair
LABOR TOTAL '..
RECEIVED & AUTHORIZED BY
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SUB TOTAL
SALES TAX
LABOR
"TERMS: C~sh upon presentation of bill.
Past due amounts subiect to service char(3e
TOTAL
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