HomeMy WebLinkAboutCC 4 CLAIM #81-28 11-02-81~TE:
TO:
FROM:
S UB,J ECT:
10/23/81
CONSENT CALENDAR
No. 4
11~2,~81
Inter-eom
HONORABLE MAYOR AND CITY COUNCIL
JAMES G. ROURKE, CITY ATTORNEY
CLAIMANT: HOYT, RICHARD M.; D/L: 10/4/81; FILED W/CITY:
10/13/81; CLAIM NO: 81-28; CARL WARREN FILE NO: 30178 ABJ
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
CLAIM 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 be ~lled 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 Way, Tustin, California 92680
TO THE HONORABLE ~YOR 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:
1. NAME OF CLAI~%NT: ~c~(~<o fy\, ~
a. ADDRESS OF CLAIt~%NT:
b. PHONE 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 than above:
3. This claim is submitted against:
The City of Tustin only.
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:
4. Occurrence or event from which the claim arises:
a. DATE': ~ C- ~1- ~ % b. TIME: / ~:1~ ~. ;~1. c. PLACE Exact
and specific location,:-- ,~e_6
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. ~ha~ pa~La~ ac~on by ~he C~y, o~ ~a employees, caused ~he
a~e~ed damage or ~n~ury?
· 6.
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
injuri~ es" .
Give the name(s) of the City employee(s) 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: ~'=2~. ~
b. Estimated amount of future costs: ~
c. Total amount claimed: ~ ~
d.
Basis for computation of amounts claimed (include copies of all bills,
invoices, estimates, etc.:
WARNING: ~T IS A CRIMINAL OFFENSE TO FILE A FLASE CLAIM'.
Section 72; Insurance Code Section 556.0)
10. Names and addresses of all witnesses, hospitals, doctors, etc.:
d. ~--~.~ -~. ~.~.~ ~.~%c~:.~t-1 .~,~.~,~ i .~ c: ~ ~ -~ ~ ·
~..l~y additional lnfo~ation' that might be helpful in~.gonsidering, this claim:
(Penal Code
I have read the ~atters 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
dpon 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 ~ :~-b~-.- , 19, %'/ , at Tust~q, California.
Office of the City Cl'erk,
Tustin, California
NO: f.{." -
'"'i ,'. 7'/
Revised 8/05/81
JGR:se:R:8/5/81 (A)
T301 H°rth Tustin *venue (714) 547-0511 ' ,
CLUE*,, iS. A. It. )
iNS.
SANTA ANA, CALIFORNIA 92701
BUS.
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7
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Stotlg~ will bo ~ ~8 hOUrS ehit ~m~iole m~lrs ow pr~nlmm or ·f~r compiled .
PHONe.
COO!
.... ~'.oN'~" ' -'" .'"' ':' '
13
15
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OPEN ITEMS
I~TE ..................................... AM Time PM ...................... .AMOUNT ...............................
PARTS PRI(~.S he~ on Standard C~tolo&qJe, & ~ CJM/¢GF.S WITHOUT HOTlY-
Service Cbe~es my he Iddld fog' special items n¢~ a~liisbis IQCally. RE]~4~r~ PAKrS
JUNK,~), uni~ OM~' ask~ Return o! Palls when order is pisoKL Abo~ e~imatl based
~--~his ~nsda~on. AddiUonal Parts, or Labor, may b~ required alter the wo~ he~.opened
,~ee ixeviou~ obscme~. ESTIMATE ~IRES 30 DAYS AFTER DATF~
thereto. I hemb~ waive the Statute M Umltatimts ind if any adJa~ mi this _~'~'~_~_'"t r~loims
emplo.~t of In ittomny I agfw~ to pay J~% inte~ pm' nTc¢lth, which ia InllOil
I Iw~ read the ahev~ ~ · copy, and ab(~ wMt h~ eNth~
(O,w/~4,nt) ey ............................................................ Dm ..............
INSU~NCE DEDUCTIBL~ HUST 9[
PAID ~FOP, E CAR IS RELF_4SED.
(net) PAKTS
PAINT HAT'L
SUB NET
$A~S TAX ':~ ~ ~
~v. C~r~
Emro,eNd nv TOTAL $