HomeMy WebLinkAboutCC 7 CLAIM #82-15 06-07-82DATE:
TO:
FROM:
S UBJ ECT:
May 12, 1982
CONSENT CALENDAR
6-7-82
Inter-Corn
HONORABLE MAYOR AND CITY COUNCIL
JAMES G. ROURKE, CITY ATTORNEY
CLAIMANT: BAKER, Adella M. D/L: 4/21/82
FILED W/CITY: 4/30/82 CLAIM NO: 82-15
CARL WARREN FILE NO: 31771 AB
After investigation and review it is recommended
that the above-referenced claim be denied and the City Clerk
directed to give proper notice of the denial to the claimant
and to the claimant's attorney.
JGR:se
Enclosure
1. Copy of Claim
cc: OCCRMA
*CLAIM AGAINST THE CIT¥CF TUSTIN
('For Damages to Persons or Personal Property)
RECEIVED
U.S. Mail ~C ~ via
Inter-office Mail
Over the Counter
The law provides generally that a claim must be filed with the Q~ity Clerk of
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 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: ( ~ c. DATE OF BIRTh: ~'-- ~--
SO¢ A ORXV RS
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:
3. This claim is submitted against:
The City of Tustin only.
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:
4. Occurrence or event from which the claim arises:
ae
de
DATE: ~t~ ~/~ /t?~ b. 'TIME: /~?/~/,.~ ~",-E/~F! C. PLACE (Exact
and specific location):
/
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).
ee
What particular action by the City, or its employees, caused the
alleged damage or injury?
-r-r f l"r
5. 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".
6. Give the n~e(s) o~ the City employee(s) causing the damage or inju~:
Name and address of any other person injured:
8. Name .and address of the owner of any damaged property
i
~mage~ claimed:
a. ~ount claimed as oE this~ date: ~f/
b. Estimated amount o~ future costs:
C.
d.
10.
Total amount claimed: . ~'~-~.L~!
Basi~ fo~ computation of amounts c£aimed (include copies of all billm,
invoices~ estimates, etc.: /~& ~-b=/~y /q0;~)/~ ~d'. z~-~T/~l/~-~ ~£.&~-z3
Names~ and addresses oE all. witnessea, hospitals~,, doctors, etc.:
a. ¢'o A-"i fl- ,'~,k'C--~,. ..c,4- ~ ,~-~"~o,'-..f ~,:-?~/do~,,~ r.~/,,,.,",~k,...'.
b.
C.
do
Any additional, information tha~ might- be. helpful ir~ consideu--ing 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 ! know the
same to be t~ue of my ow~ 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 ~RUE AND1 CORRECT.
Office of the City Clerk,
Tustin, California
CLAIMANT ' S SIGNATURE
R~vised 8/05/81
JGR:se:R:8/5/8Z (A)
NAME
SALES AND SERVICE
201 NORTH MAIN STREET
SANTA ANA, CALIFORNIA 92701
:)ORESS City
MAKE~ YEAR-MOOELTf '~ I '/ { IDENTIFICATION NO.
NSURANCE CO. ADJUSTER
ESTIMATE
R.O. No.
Phone
MILEAGE
FILE NO.
7
9
10
11
12
13
14
15
RE- RE- LABOR
PAIR PLACE
3
PARTS
MISC. SUB~.ET
The above is an estimate based on our inspection and does not cover any additional parts or labor
which may be required sftar the work has beer startm3. Occasionally after the work has started Labor
damaged or broken parts are discovered which are not evident on the fl~t Inspection. Because of
this the above prices are not guarantee(L Old parts removed from car will be junked unless other- Parts
wise instructed in writing. Availability of parts not guaranteecl.
Miscellaneous
We will not be reelmneible for I.e or damage to your car or its ¢cate~ts caused by flr~, theft,
RECAP
cldem or any other cause beyond our no~tmL /'~ ~..bl.~
',,on',
By ............................................................................. SUB-TOTAL
ADVANCED CHARG E,~"~
l/We .cceot t ,is estlme, Owner ,.AND TOTAL
Slgn~ ~ / ~ Owner's ~ent Paid by Insur~
By ~ For In~, ~, INVOICE