HomeMy WebLinkAboutCC 3 CLAIM #88-6 06-06-88 CONSENT CALENDAR
CITY ATTORNEY
CLAIMANT: NEILSON, KEITH; D/L:
W/CITY: 1/28/88; CLAIM NO: 88-6;
S53036PRC
1/22/88; DATE FILED
CARL WARREN FILE NO:
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.
Assistant City Attorney
JGR(F4.se)
Enclosure:
Copy of Claim
'CLAIM AGAINST THE CL' - OF TUSTIN
('For Damages to Persu..~ or Personal Property)
Received by
U.S. Mail
Inter-office Mail
Over the Counter
via
The law provides generally that a claim must be filed with the City Clerk o~
the City of Tustin within 100 days after which the incident or event occurrec
Be sure your claim is against the City of Tustin, not another public entity.
Where space is insufficient, please use additional paper and identify inform~
tion by paragraph number. Completed claims must be mailed or delivered to t~
City Clerk, The City of Tustin, 300 Centennial Way, Tustin, California 92680
TO THE HONORABLE MAYOR AND CITY COUNCIL, City of.~Tustin, California:
The undersigned respectfully submits the following claim and information rel~
tire to damage to persons and/or personal property:
a. ADDRESS OF CLAIMANT: ?& ~
b. PHONE NO: D TE RTH:
SOCIAL ~
~ 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:
The City of Tustin and the following employee(s) of the
City of Tustin only:
Occurrence o~ event from which the claim arises:
a.
DATE: //o-v~ %/ b. 'TIME: -$'--~ /~7 c. PLACE. (Exact
and specific 'location): /~/
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).
What particular action by the City, or its employees, caused the
alleged damage or injury?
Give a description o~ the injury, property damage or loss so far as is
known at the time of this claim. If there were no injuries, state "no
injuries'[. -
0 ~
6. Give the name(s) of the City employee(s) causing'the damage or injury:
7. Name and address of any other person injured: ~__~
e
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.:
i0. Names and addresses 9f all witnesses, hospitals, doctors,~etc. ~
b. , ,-
11. Any additional information that .might be helpful in considering this claim:
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 t~e 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 penal~ of perjury that the foregoing is TRUE AND CORRE~.
Executed this~ ~ day of , , 19 ~ , at Tustin, California.
~ CLAZMA~'S SIGNATURE
~fice of the City Clerk,
stin, California
CLAIM NO: f~--~
Revised 8/05/81
JGR:se:R:8/5/81 (A)
0002819
KELLY'S BODY SHOP ;'~
2041 So. Main Street - Pt~one (714) 54L
Santa Ana. CA 92707
,86
,Jo
Owner / ..... j
Address
Year 7~,'2 Make [,/~//4J Model
ESTIMATE OF REPAIRS
city
License Number
Regalr Replace Mileage
I:)ESCRIlarl'ION OF LABOR OR MATERIAL Labor Material Sublet
PARTS PRICES BASED ON STANDARD CATALOG PROCUREMENT PRICE LISTS SUBJECT TO Total Labor
CHANGE WITHOUT NOTICE. PROCUREMENT AND DELIVERY CHARGES MAY BE ADDED
FOR SPECIAL SERVICE ON ITEMS NOT AVAILABLE LOCALLY, Total Material ~'"O ,?..~
Old parts removed from cars will be junked unless otherwise inslructed in writing· Sublet ~/,~' -'~,~ "~¢
The above is an estimate based on our inspection and does not cover additional parts or labor v -
which may be required af.t~r th~it work~:t~..s been opened up, Occasionally after work has started Paint Job
worn parts are disco..v~r%}' wh~h ar..e"'not.~evident on first inspection. Because of this the above
prices are not gu,~afly/: .~ ~
Estimated By/ ~.,??? ..-'~ Estimate Approved By
By Owner or Agent Date