HomeMy WebLinkAboutCC 11 CLAIM #87-7 03-16-87TO:
FROM:
SUBJECT:
HONORABLE MAYOR AND CITY COUNCIL
CITY ATTOI~EY
CLAIMANT: MARTIN SOLBERG; D/L: 1/19/87; DATE FILED W/CITY:
1/23/87; ~.&IM NO: 87-7; CARL WARREN FILE NO: S50179CVH
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.
JGR (F4. se)
Enclosure:
Copy of Claim
CLkIM AGAINST THE CITY OF TUSTIN
('For Damages to Persons or Personal Property)
Received by
U.S. Mail
Inter-office Mail
Over the Counter
via
The law provides generally that a claim must De filed 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 the
City Clerk, The City of Tustin, 300 Centennial Wa~, 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:
a. ADDRESS OF CLAIMANT: ~
b. P.ONE NO: ( '?~- c.
SOCIAL ~
d. SECURITY NO: ~ e.
DRIVERS
~ICENSE 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:
,,X The City of Tustin only.
a.
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:
e
Occurrence or event from which the claim arises:
a. DATE: ! //~ /'~"/ b. 'TIME~.~,'O~ ~C ~. ,~. C. PLACE (Exact
and specific Iocatio. n):
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?
Give a description of 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".
Give the nam. Cs) of the City employ,eCs) causing the damage or injury:
7. 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: /00,~. '7~)
b. Estimated amount of future costs: ~ ~.-
c. Total amount claimed: ~ / Oo ~°. ~ ~
d. Ba'sis for computation of amounts_claimed (in~L~ude copies of all bills,
invoices, estimates, etc.: ~a~rf~ ~I'-{/,~,~/-~S /c~'~->~/~-~) (~c ~
10. Names and addresses of all witnesses, hospitals, doctors, etc.:
11.. Any additional information that might be helpful in considering this claim:
c~Ty O~ To~7'/~) Ce~ cRe~J P.~,,~oo'ea TR~.
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 J~A2~/~/ , 19 ~ 7 ' at Tustin, California.
=.ice of the City Clerk,
~stin, California
CLAIM NO: ~?~ 7
Revised 8/05/81
JGR:se:R:8/5/81 (A)
'.MAN CHEVROLET CO.
1800 EAST CHAPMAN AVE.
ORANGE, CALIFORNIA 92666
(714) 633-3521
SHEET NO. OF SHEETS
PHON~
Szoriee w be cher~ M hou~ ahw v~lcle ~tMt o~ M~IM, or I~l~pl~ ~BOR PA~S LIST
~
X -
.
MASTERCHARGE ~ VISA n,
(S)
..................................... W ~m W ........................... M~NT ................................... ~EN ITE~ (ne~) PARTS
PRI~ ~ 0n S~n~M ~M~e, & ~ ~S W~ NOTI~
may ~ aM~ ~r s~al item n~ MiMMe I~ily. R~
i~ion. ~onal P.~ or ~.r, m. ~ ~ui~ after t.
be d~ H ~r em~ m.m.~ ~ui~ te~ *t ~ ~ ~ ~ SUB~T NET
/
wlive the ~, ~ Umiaks and if ,~ ,~ ~ this ~ mui~ ._: ~ ................ SA~S TAX /
~ ~ ~m dire. ~,~*~* J.~'s f. ~ ~ ~ PAID B~O~ C~ IS ~E'~ASED. EST I~TE TO~~
'~'LIT'Y & SERVICE JOHNSON'S PAINT AND BODY SHOP
,/ER 35 YEARS 406 EAST SANTA AHA BLVO.,
SAHE LOCATION SANTA ANA, CALIFORNIA 92701
(BAR) - AB-6'~gq. 6-R (714) 543-9479
ESTIMATE OF REPAIRS
ZiP
ADDRESS CITY CODE
1
,o .,. _
"' ~. ...~:~ ~'~" _~. ,
17
18
19
20
21
22
23
24
25
Hrs. e ~BO~
A. ~L Work OK'd By ....... : ........................ TO ................................
DATE ....................... AM Time PM ...........................
PA~ PRI~S ba~d on Standa~ ~lo~ue. & Prim C~NGES WIT~T NOTICE.
~iM Cha~ may be added for s~al items not available I~lly. R~ PARTS PAINT HAT~ L
JUN~D. unle~ O~er as~ Ream of Pa~s when order is
on this ink,ion. Mditional Pans. or ~r. may ~ r~ui~ after the ~rk has o~ned
up damage pr~i~y obs~red. ESTIMATE EXPIRES 30
My ~r will be driven by your employes to.~ r~uir~ tes~ at my risk. ~ expr~ ~UB~T NET
m~wc's u*. is h.re~y ~o.,edpd o..bo, ve,i~e to ~re the
thereto. I hereby waive the Statute of Limitations and if any action on this ac~unt requires
employment of an a~omey I agree to pay l~/z~ interest' ~r month, which is annual iNSU~NCE DEg'~ig~ ~ST BE
pef~n~ge rate of 18% from date, reachable aUo~'s f~ and ~u~ costs. P~ID BEFORE CA~' IS RE~ASED. ESTI~TE TOTAL_
I h~e ~ad the a~e. recei~d a co~, and able work hereby authorized " ~ ,~ ~_~ Adv. CHarges
(Owner/~ent) By .................. Date ....... ~ ·