HomeMy WebLinkAboutCC 3 CLAIM #81-10 06-15-81DATE: June 1, 1981
CONSENT CALENDAR
6-15-81
No. 3
ln er-C m
TO:
HoNoRABLE MAYOR AND CITY COUNCIL
FROM: JAMES G. ROURKE, CITY ATTORNEY
SUBJECT: SHAWN DJERF, Claim No. 81-10, D/L: 2-8-81, Date Filed w/City:
3-27-81, Carl Warren #28776 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. Claim of SHAWN DJERF
.t ': CLAIM AGAINST THE (" Y OF' TUSTIN
" (F~r Damages to Persons or Persona] Property)
;ceived By via
t.!.S. Mail ~
Inker-office Mail
Over the Counter
The law provides
generally that a claim must be filed with the City 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 information 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 relative to damage to
i. NAME OF CLAIMANT: .~H ;~ [.,~AJ
a. ADDRESS OF CLAIMANT:
·. b. PHONE NO: ( ¢ c. DATE OF BIRTH:
_d. 5OCIAL SECURITY NO: .~'
'~
2.
than above: /xt~.cO ~rit>D/~e-B~% '
-- 7. 0ccu~ence or event from which the claim arises:
a. ~iTE: ' 2: S~- ~ ~ b. zI~E: I': ~7~- P4 c.
location) ()..Q '~IN ~
d.
Name.. telephone and post office address to which claimant desires notices to be sent, if other
PLACE (exact and specific
How and under what circumstances did damage or injury occur? Specify the particular
occurrence, event, act or emission you claim caused the injury or damage (use additional
paper if necessary).
/4 cc / lb,z4,,7" ( z .; ,'l . ~
What particular action by the City,
injury?
~ C / mY r)(,.'/,., ~-/') C,~'.
or its employees, caused the alleged damage or
D
ADOIT~OHr,-,L
7-(j ' 7-H E
~A~ E
~, c ~'
~ DOiTIONRt.- Pr~&~
T 6.~ .5 5ouTHBou.,vO o/u /-fFr/N
FRo.~,I T'HE Cu,~r~ ~i THOU T FIR~ST CHE~KII~
/4 E ~ T,~UC K THE ,~/'d-/-/T ,5 / D ~ z~r_~,¢
Give a description of( .,c injur),, proper[), dama§e or los , so far as is known at the time of
this clai[n. If there were no injuries~ slate "no injuries".
Give the name(s) of [he City employee(s) causing the damage or injury:
Name and address of any other person injured:
Name and address of the owner of any damaged property:
Damages claimed:
a. Amuunt cis~.:'~ed as o[ this da.~: 1~'~6 ~' ~-
b. Estimated amount of future costs: ~Z~. ~ ~
c. Total amount claimed: f~G- ~22
d. Basis for computation of amounts claimed (include copies of att bills, invoices, estimates, '
etc.):
10. '
Names and addresses of all witness, hospitals, doctors, etc.
b.
Any addir, iona! informa,'ion that might be helpful in considering this claim:
· .. ,--.:.- .... - r-o.~4~., ^ OC'F='~'~S~' TO ~'n v A FALSE CLAIM! (Penal Code Section 7Z;
,~ .~ .... ~ .,~. I;~'~ A ~, .~,-,~, ..~L ..........
Insurance Code Section 556.0)
! have read the matters and statements made in the above claim and ! know the same to be true' of my
own knowledge, except as to those matters stated to be upon information or belief as to such matters !
believe the same to be true.
CORRECT.
Executed this ~--i day of
Office of the City Clerk,
Tustin, California
CLAIM NO. ~ //'-~/'~
certify under penalty of perjury that the foregoing is TRUE and
at Cr eo4./ .California.
Claimant's Sig~ur8 '-
DATE FK-ED: Z'/z --~F~ oC>/
JGR:se:O:2/~/80
T/Claim Form D:iI
TRAFFIC COLLISION REPORT . ( '- --;- -'.:'.--:. ':-~' :T;'"! ....... '--
~ Traffic I . O CHP ' ' CITY OF GARDEN GROVE ' '-, Hit & Run ~z.~',~o~-
I~ ~..ic E~. - [] Other: ..~ COUNTY OF ORANGE 't 15. i~. Prop. E3 I~o¢. D,,m~e '
- ~;on.occurrmcl on: ~ . · · I Mo. DA~ Yr ITi.,r~..~2.~CK~'t ell No, IOt~cer Name &
I I A Lo.ter-.~:' ' -- -- -- ,~ / ' ~ ' j O~r~ I Inll I ow~y ] Sta~ H~
'PARTY N~ . J ~ _ PhoneN~ ~ ..
· ... A - -- Ci / ...... '< '::.' -~ ~- ':--~ .......... ,':
0 .7~" ~ - ~ ~' ' .... O~ ' ': ~-~;:::-:' ..T'~; ........ 7 -'.:~ -.~:..
' ~ ..'/~,~¢r/ ..... ~/ ~/ . F~ ~'-': ~- . ......... - :
PAR~ N~'' / --*. ~ , ~ne~o= "' ~ .... i'-' - '.~l- ~ .....
_~ ~~ ~~ ~j ~ ,~-~ _ - ....~- -. ~' ~-. .... '----:,~..
~. Or~ Li¢~ ~. ~ ~ . ~ 8i~da~ - - ~ ................. -=t _:
~ ~~ .... ~. ~_~;-~ .. ,-. :._. :_:.. .....
~d Veh. Y.~! V~ ~ke , U~ ~1~ ~ .. .. I : * -, . . :
- ~ - * ~¢ ~ ~~ / l - .. ~.: ...........
~< C V 'c~ icen ' D' ' fT~l~ ~ - ~ .....
, 0 ~/~0 · - · . ~ ~/~ ~~ ... ~- - ~. ' - - '-~
· WiL ~ C~plain~ of Pain ~ Pe~ ~ Bi~cI~ ~ ~ '
Inj. Sex Addra~l
I
· [ .;a Narn~
;o'--~ No. 502 12,/771
Addmeal ~
Other Viable Injuri~l [] Drive' ' []
Cocnplaint of Pain [] Pa~&eng~ [:~
P.d . 0 ~/eh. No.
Bicycli~'t []
/
PhoM,
I
~..~Continuation
Supp[ement Time: / ~'<~
(List any persons to be carded)
Incident/Arrest Narrative
GARDEN GROVE POLICE DEPARTMENT
%
' Type of Repo~
Page / of
List all suspects and complet~ vehicle description and witnesses. Include DOB, sex, street address, city,
phone, and zip code if known. Refer to persons listed by last name in narrative. Do not use names that
are not listed.
"IJ Officer~,~& No. ~.~j~ I~ J Approved By
_~AME ~ °
DDRESS
CITY
OME PHONE
Body
FOREIGN & DOMESTIC COLLISION REPAIR
PAINT SPECIALISTS
321 E, First Street, Santa Aha, CA 92705
547-9621
13961 Enterprise Drive,Garden Grove, CA 92643
554-6240
MA'*E YEAR
"70
MILEAGE
WORK PHONE
LICENSE
SERIAL NUMBER
ISURANCE CO.
POLICY # or CLAIM it
'/ /
COLOR CODE
I-I REFINISH COMPLETE
[] ACRYLIC ENAMEL
n ACRYLIC LACQUER
ITEMS LISTED WILL BE SUBLET
GLASS RADIATOR
BUMPER UPHOLSTERY
OTHER
o-Z~-7_(.
o -7_ tq
ALL REPAIRS CASH OR CERTIFIED CHECK
SUB TOTALS
¢lmi:~ty Revised OK'D
icstir: $ Estimate S By
[]In Person E:] By Phone
~ .storr~r Acknowledges I~eceiDl Ot A C~y Here~:
)o - Do Nol Wish To ~ve My Old
5~g~re X By
~th~iz~
~ .L REPAIRS CASH OR CERTIFIED CHECK
LABOR
PARTS
PAINT MATERIALS
SUBLET WORK
ADVANCE CHARGES
GRAND TOTAL
u/06
'47
F_.STII~TE OF REPAIRS FOREIGN & DOMESTIC AUTO BODY & PAINTING SPECIALIST