HomeMy WebLinkAboutCC 3 CLAIM #85-45 11-18-85 '~1~ ~ r ]~ I .~ ~ ~ CONSENT CALENDAR
_~ ~,~ '- . NO 3
SUBJECT: CLAIMANT: SMITH, KARYN LYNN; D/L: 09/09/85; DATE
FILED W/CITY: 10/04/85; CLAIM NO: 85-45; CARL WARREN
~ FILE NO: S43746CVH
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
CLAIM AGAINST THE CI~_.OF TUSTIN
'~or Damages to Persons or Personal Property)
.,eceived 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 occurred.
Be sure your claim is against the City of Tustin, .not anon. her 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 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:
a. ADDRESS OF CLAIMANT:
b. PHONE NO: (~
~ DRIVERS ' '
d. SECURITY NO: _~-~!-~ ~%~ 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 or event from which the claim arises:
a. DATE: 9/~/~' b. 'TIME: ~'.%~.~ . c. PLACE (Exact
and specific location): ~r~~.~-~k~l!
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?_ ~ ~~.
o %1 ' ' q '
~ive 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
Give the name(s) of the City employee(s) causing the damage or inju~:
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: ~A% ~
c. Total amount claimed: ~ ~-~
d. Basis for computation of amounts claimed (include copies of ~11 bills,
invoices, estimates, etc.: ~.~ ~I~ .... ~l-~ ~ ,~..~'r~j.
0. Names and addresses of all witnesses, hospitals, doctors, etc.:
a,
cJ
de
~ny additional information that might be helpful in considerin_g this claim:
ARNING: IT IS A CRIMINAL OFFENSE TO FILE A FALSE CLAIM: (Penal Code
Section 72; Insurance Code Section 556.0)
have read the matters and statements made in the abov~ claim and I know the
ame to be true of my own knowledge, except as to those matters stated to be
pon information or belief and as to such matters I believe the same to be true.
certify under penalty of perjqry that the foregoing is TRUE AND CORRECT.
ixecuted this r~~/ day of~/t~/O~./~,_~.~[~ ~ _ ~ ,
19~, at
Tustin,
California.
)ffice of the City Clerk,
'ustin, California
'~ NO: ~
/ ' ' ./ 'CbA~MANT' S SIGNATURE
DATE FILED:
{evised 8/05/81
~GR:se :R:8/5/81 (A)
~714) S54-6240
ME PHONE
llAL NUMBER
~URANCE CO.
FOREIGN & DOMESTIC COLLISION REPAIR ~
PAINT SPECIALISTS
139~1 Enletprlle Drive · Ga~leo Gray, · 321 ~t Flrtt Strut · ~ntl Ana
(714) ~7-~21
WORK PHONE. LICENSE
COLOR CODE ITEM5 LISTED WILL BE SUBLET
~ REFINISH COMPLETE GLASS RADIATOR
~ ACRYLIC ENAMEL BUMPER UPHOLSTERY
~ ACRYLIC ~CQUER OTHER
/ ..-..
NO PERSONAL CHECKS
ALL REPAIRS CASH OR CERTIFIED CHECK SUB TOTALS
,r~e~eOy au horizl ~ alx),l re~lir wark to bi dOe¢ am,O with Ui~ nec~s, saf~ rear.ills, you a~ y~r ~~ LABOR
vehicle f~ ~r~ M ~Uq. I~m ~ ~ at q r ~. AA .~m ~'S I~ ! ~n~ ~
'mllmi~ R~i~ OK'D
~sa~ $ Esa~m S By SUBLET WORK
PA~ INSTA~D ARE N~ UN~ ~CIFIED O~ISE ~ In P~s~ ~ By
PA~ RE~ED ~ BE ~ UN~ ADVANCE CHARGES
TAX
x
FOREIGN & DOMESTIC AUTO BODY & PAINTING SPECIALIST
ESTIMATI= ~1= Rt=PAIR~
BODY & PAINT
816 E. 1st St., Santa Ana, CA 92701
Telephone (714) 834-0424
DATE
REPAIR ESTIMATE
ESTIMATED BY
RESS '"t
~AR MAKE I MODEL
LIC. NO.
PHONE
BODY STYLE
SPEEDOMETER
READING
'AIR DESCRIPTION
PARTS {~ LIST LABOR HRS R E F SUBLET
COMMENTS:
HEPA~F~S HAVE BEEN COMPLETED.
dORIZED SIGNATURE
LABOR HRS.
REF. HRS.
TOTAE
LABOR HRS
DATE
PART, ~1 LIST ~
SUBLET ~
PAINT MATERIAL ,--~ '~'-, ~'
TOTAL ~, ~ %