HomeMy WebLinkAboutCC 5 CLAIM #88-10 06-06-88~AT[:
MAY [8, 1988
CONSENT CALENDAR
NO, 5
6-6-88
Inter-Corn
FROH:
S U6J £CT:
HONORABLE MAYOR AND CITYCOUNCIL
CITY ATTORNEY
CLAIMANT: GOLON, RAYMOND; D/L: 1/18/88; DATE FILED
W/CITY: 2/16/88'; CLAIM NO: 88-10; CARL WARREN FILE
NO: S§3098PRC
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
· ~'~ AGAZNST THE CiTY OF TUSTIN
(?or Damages ~o Persor r Personal Proper~y)
~eived by
~.S. Mail
Inte~-office Mail
Over the Counter
via ·
The law prov~es generally =~a= a claim must De ~l!ed
the City of Tus:in-within !00 days after which ~he in¢iden~ or even~
Be sure your claim is agains= the City of Tus~in, not another public en~i~y.
Where space is insufficient, please use additional paper and identify informa-
tion by paragraph number. Completed claims must be mailed or delivered' to ~h¢
City Clerk, The City of Tustin, 300 Centennial Way, Tustin, California 92680
TO ,..E HONORABL~ MAZSR AND CiTY COUNCIL, City of Tus=in, CaLifornia
The undersigned respectfully submits the following claim and information re!a=
tire to damage to persons and/or, personal proper=y:
a. ADDRESS OF CLAIMANT:
NO: c.
SOCIAL
DATE OF BIRTH:
DRIVERS
LICINSE NO:'
.Name,. te!eDhone 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 Ciny of Tus=in and =~e following employee(s) of ~ne
City of Tustin only:
Occurrence or event from which the claim arises:
d. How and under what circumstances did damage or injury occur? Specify
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?
ire a descrip:ion of the inju.'"Z, ?roper:y .~ama9e or loss so far as is
known aa the time of this claim. ~f there were no injuries, s.~ate "no
injuries".
Give ~he name(s) of ~e 'City empioye~(s) :~using the damage or inju~:
7. Name and address of any o=her person injured:
8. Name and address of the owner of any damaged property:
9. Damages claimed:
a. Amount claimed as of this date: ~l ~) ~ (/£~f ,~ ~ .~ F~/
b. ~stima~ed amount of fu~urm
c. To=al ~oun= claimed:
d. Basis for com~uta=ion of amounts claime~ (lnc!ude copies o= al! ~I~
invoices, estimates, et=.:
10. Names and addresses o~I! wi~nesses,"hos:ita!s, docto~, etc.:
!1. ~Y additional info~ation =ha= migh= be he!pfu! in considering ~his
WARblING ':
iT IS A CRIMINAL OFFEIqS-~ ~£O fi'~,E A ?ALSE CLAIM[
Section 7~; Insurance Code Sec=ion 556.0)
(Penal Code
I have read the matters and ~.=a-=amen'~s made in ~he above claim and I know ~he
same to be ==aa of my own knowledge, except as ~o those matters stated to be
uDon information or. belief and as =o such matters I believe the same ~o be =rue
I'cer=ify under pena!T/ of perju~! Chat the foregoing is TRUE ANp COPd~ECT.
Zxecuted this /5' day of ~~/ , 19 ~ ~ , at Tustin, California~
O~ .ce of the City Clerk,
Tustin, California
CLAIM NO: ~: ? - / ~
Revised 8/05/81
JGR:se:R:8/5/81 (A)
B.A.R.) AA-71-N
,ME
)O~ESS
DATSUN
aUS.
PHONE
NO.__OF SHEETS
PHONE
COOE
LABOR PARTS LIST
12 .
A39~ ................. AM ~ ~ ............................ AMOUNT ............................
OPEN ITEMS
(net) PARTS
PAINT MAT'L
I~;SURANCE DEDUCTIBLE MUST BE
SUBLET NET
SALES TAX
ESTIMATE TOTAL
AOv, Charqe$
TOTAL $
I
"ST 'E OF REPAIRS
30.o<. 30 days only
qSURANCE CO.
~-'RONT OF CAR
:~I.IMPER
CALIFORNIA CLASSICS
PAINT & BODY SHOP
1650 E. ED~NGER. SANTA ANA, CA 92705 ~, .?../~ ~
(714) 542-9811 ~.~, ~ ~
~,f ~2 ~., ~ ,~ ~ PHONE ~.-~ ~ .. ~..
-- Pro0aDle
ADJUSTER Oown Time
Lal3or I
Hours ! Pans Sublet LEFT SIDE
I ~NOER
t Fender Skil~
PHONE NO.
HoursLaD°r Parts
i
I
C~ille Mldg. ! {
i *
Gdlle 8r~t, [
Raoiitor
,mud
8fade
,-'an
H~ Mldg.
LaOor Sublet i
Hours Ps~s RIGHT SIOE
{ i i I Fender Ext.
Fender MId~. I i [ I Fender Midg.
w.o. ~,dg.~ I ~ ~ w.o.
Hemalamp ( I ( ) Hea~lam~
Heedlam~ Oeor I ~ I d Hemalamo ODOr
Sealed ~leem
Part<. Lidnt
Side Mart(. Lamo
0OaR. FRONT
ODor Rein f.
ODor ,~ld ,d.
ODor Handle
ODOR. RF_.AR
Door Midg. I
i Seaie<t Seam
I Pa~. t.ignt
REAR OF CAR
Side MarK. Lama
ODOR, FRONT
Ooor Hinge
ODOr MIdg.
Door Handle
Door, Glass
A.C. CONDENSOR I · I -- QUAR. PANEL
,q~-~,~e A.C. i. i ' r't ! Ouar' '~xt'.r ~
~,ir Cam3. Line I ~' I I Qusr, Wheel Hsd.
/ m ~ r X I ..... " a,,~.aid,
~ t , ~ Side Ma~. Lame
I~umoer Ralnf.
Bumper Gua~
~ latch
Name Prate
SPINDLE
Tire ~,~ Worn
Hut) CaD
bio ~t. Shaft
~ow Cont, Arm
Low Cont. Shaft
WINL~SHIELD
Adheswe Kit
OOOR, ~EAR
Door Mldg.
Center Post
BodN Panel
Gravel Shield
Floor
I Rocxer Mldq.
I QUAR. ~ANEL
TRUNK LIO
Truna Lid Mldq,
T nj nt~ Hinge
Trunk Loci<
Llc Light
Ouar ,Nlid~.
Wheel. aden Midg.
Tail Lamp
Side Ma~. Limo
MISC. ITEMS
Quar.
Ouar, Wheel Hsd.
Ooq Le~
8a[ter~
Oas
Frame
U~dercoaf
& Storage
Relinisn Ae Nec.
BacK-up Light
RECAPITULATION
'Moulding ! , I Ii
Open Items
if the customer wishes to claim used and/of damaged Darts. pteaae cnecl< this bOX
Tax $ <',~'~'-
Material $ ~r ''~ ' V
Subie! S
TOTAL S / _/ '_~