HomeMy WebLinkAboutCC 5 CLAIM #83-6 06-06-83DATE:
TO:
FROM:
SUB,JECT:
5/25/83
CONSENT CALENDAR
No. 5
6-6-83
Inter-eom
HONORABLE MAYOR AND CITY COUNCIL
JAMES G. ROUiRKE, CITY ATTORNEY
CLAIMANT: CARSTENSEN, JA~S L.; D/L: 12/7/82; FILED W/CITY:
12/7/82; CLAIM NO: 83-6; CARL WARREN FILE NO: S 34178 AB
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':se
Enclosure
1. Copy of Claim
cc: OCCRMA
RECEIVED
· (Fo~ Damages to Persons Personal Property) _
' Received by~~,~--- via
u
$I983
ater-office Mail
Over the Counter
The law provides g~nerally
the City of Tustin within 100 days after which the incident or event occu~ed.
Be sure y~ur'claim is against the City of Tustin, no= another public entity.
Where space is insufficient, please use additional paper and identify info,a-
tion by paragraph n-m~er. Completed claims must be mailed or delivered to the
City Clerk, The City of Tustin, 300 Centennial Way, ~stin, California 92686
TO THE HONORABLE MAYOR AND CITY COUNCIL, City of Tustin, Ca. lifornia:
The undersigned respectfully submits the following claim, and information, rela-
tive to damage to persons' and/or personal property:
1. NAME OF CLAIMANT: ~,=~ L. (~,,~,~_jcT.~.
a. ADDRESS OF CLAIMANT: / ~
b. PHONK NO: (-~// .~ c. DATE OF BIRTH:
SOCIAL DRIVERS
d. SECURITY NO: _ ~- ~??~ ~ e. LICENSE NO:
2. Name, telephone and post office address to which, claimant desires notices.
to be sent, if other' ~han above:
¸®
This claim, is submitted against:
~/ .' The City of Tustin
a.
b. The following employee(s) of-~he. City of Tustin o~ly:'
The City of Tus=in and the. following employee(s) of the
City o~ Tus=in only:.
4. Occurrence or event from which the claim arxses-' .
How and under what circ,~etances did damage or injury occur? Specify
the par~icular-o~currence, 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 d,a~age or injury.~ , / ~
~' t '~' . /
Gi,%e a description of ' injury, property damage --- loss so far as is
known at the time of %_~s claim. If there were nu juries, state "no
Givg~h~ n~e(s) of ~e C&ty empl~ee(s) causing ~e damage or inju~:
Name and add:ess of~ any.or,mr person inju:e4:
8. Name and address of the :owner o~ any damaged' property:
Damages claimed:
~: Amount claimed a-~:o~ this date: ~.~,~
Estimated amount o~ future, costs.:
c. Total amount ~aimed.--
d. Basis for computation of ..amounts clai~ed(~nclu~e
invoices ,- es=ira&tee
copies of all
10.
Names' and addresses ~ all witnesses, hospitals, doctors, etc.:
Any addi=ionai information~ t. ha=' might, be helpful in considering.
WARN ING:
iT IS A CRIHINA~ OFFENSE TO- ~ILE A FALSE
Se~io~ 7~; Insurance Code Section 556.0)
(Penal Code.
I have read the mat=ers and: statement~ made in the above' claim and I. know the
same to be true-o~ my own knowledge, except as. ~o those matters state~ to be
upon information or belief and as. to such mat=ers I believe the same to be =rue.
I certify unde= penalty of perjury that the foregoing is TRUE AND CORRECt.
Office of the City CIe~k,
Tustin, California
CLA'r~ NO.- ~-- ~
iHANT ' S SIGNATURE
r~-ised 8/05/81
~-x:se:a:$/5/81 (A}
UCEN~ENO.
PHONE HOME ~NE: E~I'IMAI~ NO:
DESCRIPTION OR LABOR & MATERIAL
638 WEST_17th ~/KEEr
COSTA Mf A 92627
642-9373 -- ~42-9375
CALIF. LIC. -~AC 62604 R
ADJUSTOR
RIETAIN PART~ []
R.O. ~k~ JUNK PAM~J~
~ * PAKI'S MMMNMS SUBLET
Aud'lO~Zm:t by Dam
· CODE N.NEW U4J~.D R.REBUILT
Adv.