HomeMy WebLinkAboutCC 4 CLAIM #86-24 08-04-86 CONSENT CALENDAR
· NO. 4
8-4.8fi,,~
Inter Corn
FROM:
SUBJECT:
~ONORABLE MAYOR AND CITY COUNCIL
CITY ATTORNEY
CLAIMANT: ROBERT MICHAELS; D/L: 05/17/86; DATE FILED
W/CITY: 6/2/86; CLAIM NO: 86-24; CARL WARREN FILE NO:
48957CVR
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.
City Attorney
JGR(F4.$e)
Enclosure:
Copy of Claim
'CLAIM AGAINST THE CIT2.10F TUSTIN
('Fo~ Damages to Persons or Personal Property)
'Received by ~F7~ ,44,c~c~lI via
U.S. Mail ~
Inter-office Mail '
Over the Counter
The law provides generally that a claim must be filed wlth the Clty 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 th
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 rela
tive to damage to persons and/or personal property:
NAME OF CLAIMANT: ~o R~WY ,'~1~1~
a. ADDRESS OF CLAIMANT: .~ ~
b. PHONE NO: (~ C.
SOCIAL
d. SECURITY NO: ~ _ e.
DATE OF ~IRTH: ~,/%/~
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:
Ce
The City of Tustin and the following employee(s) of the
City of Tustin only:
Occurrence or event from which the claim arises:
a. LATE: S//7/ff b. 'TIM : r c. PLAC IS×act
and specific ~ocation):
d. How and under what circ~stances 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?
'5. ' Gi4e a description of the injury, property damage or loss so far as is
· known at the time of this claim. If there were ng, i~juries, stgte "no
injuries". I~ /~'~ (,4YJU,~S ~
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 of the owner of any damaged property: ~o,~1~- /~ic~4~g.-~'
9. Damages claimed:
a. Amount claimed as of this date:
b. Estimated amount of future costs:
c. Total amount claimed: ~_O-~,
d. Basis for computation of amounts claimed (include copies of' all bills,
invoices, estimates, etc.:
10. Names and addresses of all witnesses, hospitals, doctors, etc.:
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 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 of perjury that the foregoing is TRUE AND CORRECT.
Executed this ~ day of ~/~f , 19 ~6 , at Tustin, California.
Office of the City Clerk,
Tustin, California
NO,
CLAIMANT ' S SIGNATURE
Revised 8/05/81
JGR:se:R:8/5/81 (A)
.rend--r mender,
auto 4)ody & paint speciali.ta
32'6 N. lEI Camino Real (619} 436-5575
En¢inita& CA 92024 e.~R ne~ #~JlO~883
kforeign car speciali
Date
In
,/rcollision specialists Date Out
~-complete frame ecluipment RO#
~rm rg welding Body
*insurance claims
~infrared cured paint
CL#/DoL Ins. Deductible
PAKTS ' REF REPAIR FRAME/
2 RPS (-L,-)F,U LClO ~ ~
3 R PS (-L R-) F R U LC I 0
4 R PS (-L R-) F R U L C I 0
5 RPS (-LR-)F R U LClOI ~;;~
6 RPS (-LR-)FRULC~OI
7 RPS (-LR-)FRULCIO~ [
8 R PS (-L R-) F R U L C I 0
.Ps u LC,O
11 R P~ (-L R-) F R U L C I O ~
12 RPS (*L R-) F R U LCIO ~
13 RPS (-LR.)FRULCIO
14 RPS (-L,-) F , U LClO ~
20 RPS (-LR-)FRU LClO ~ .-- ~ :
..................... _.~ Total .
~u~otal
Estimato. f~~ labor rote $~'La.r ~Z ~/~ ~BOR
~s or, d from {vendo~ {rep) ~;~ PARTS
prelimina~ est only D ~ SUPPLIES
~ SALES TAX
EST. TOTAL
Re~im ~ gua~nte, to cuatome,s .tis~lon unle. othe~and mat~sals ~nt~ ~r
~an~a~umr. Pa~ pdces ~bj~ to ~aier invoicL ~y ed~tio~l p~mpa~ ~eeo~ w~ ~ suoj~ to
~ by you or your insurance ~m~ny. Approximate re~r tim~ ~ng da~ Due t~
.vail~ili~ ~ ~ hidden damage, and other cimumsmnces be~ontro~e cannot guamnT~ dme oT
fe~ic
I here~ ackn~ledge receipt of estimate ~d autho~ze re~i~ I ~rant your employHs permi~ioA to te~t-dri~
are made in advance.
Authorized Signature Date COPYRIGHT 1985 Fencler Men, er. thc