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Home My WebLink About05 CONSIDER CLAIM # 06-19 08-07-06AGENDA REPORT MEETING DATE: AUGUST 7, 2006 TO: WILLIAM A. HUSTON, CITY MANAGER FROM: RONALD A. NAULT, FINANCE DIRECTOR SUBJECT: CONSIDERATION OF CLAIM OF MOHAMMAD MOSTAHKAMI, CLAIM NO. 06-19 SUMMARY: The Claimant reported he was driving on Tustin Ranch Road on June 15, 2006 and a rock from pavement construction hit his car and cracked the front windshield. He is requesting that the City pay the cost to replace the windshield and compensate him for lost work time. RECOMMENDATION: That the City Council deny Claim Number 06-19, Mohammad Mostahkami, and direct Staff to send notice thereof to the Claimant. FISCAL IMPACT: None. DISCUSSION: Staff and the City's Claims Administrator have determined that at the time of the damage to the Claimant's vehicle, the Contractor in control of the road construction in the area was All American Asphalt. On the basis of the indemnification clause in their contract agreement, and as the City of Tustin is a named additional insured under the Contractor's general liability policy, this Claim has been tendered to All American Asphalt. ATTACHMENT: Copy of Claim No. 06-19 ConsiderationOfClaimOfMohammadMostahkami.doc CLAIM AGAINST THE CITY OF TUSTIN (For Damages to Person or Personal Property) Received Via: U.S. Mail Inter-Office Mail Over the Counter Time Stamp: -:"'" ":'! 'l"- r") 1. 0, l~ (;il '\L Claim No: D(Y-IC( PLEASE NOTE: A. Read entire claim before filing. B. Be sure your claim is against the City of Tustin, not another public entity. C. Claims for death, injury to person or to personal property must be filed no later than 6 months after the occurrence (Government Code ~ 911.2). D. Claims for damages to real property must be filed no later than one year after the occurrence (Government Code ~ 911.2). E. If additional space is needed to provide your information, please attach sheets, identifying the paragraph(s) being answered. F. A claim must be presented, as prescribed by the Government Code of the State of California, by the claimant or a person acting on his/her behalf and shail provide the information shown below and must be signed by the claimant or a person on his behalf (Government Code ~ 910.2). G. This form is for the convenience of those desirin9 to present claims against the city. Claimant is advised to consult a private attorney if iegal advice is desired. No employee of the City may give legal advice to any claimant relating to private claims. H. Completed claims must be mailed or delivered to the City of Tustin, City Clerk's Office, 300 Centennial Way, Tustin, California 92780. 1. Name and Post Office address of the Claimant: Name of Claimant: /Vl 0 ~ /YJ ~ 1) IV! 0 J iI4.)1 k/:l NIt Home Address: 2. <:, z. "L. IN 0 I er I- (' + ' TiJ~f-.;' / eA 97, E L Home Telephone: q If ~ _'14 & -I' -. ( Work Telephone: 11 't - '\ \. "I - C\. C 1..- 2. Post Office address to which the person presenting the claim desires notices to be sent: (If different from above) Name of Addressee: Post Office Address: Telephone: 3. The date, place and other circumstances of the occurrence or transaction from which the claim arises. Date of Occurrence: ,J J"... \ <).' Dle Location: N";lt:'I.,,c~.\ '\1\-\-.:'" l2--~"" Circumstances giving rise to this claim: l~o U'_ f.,,~ pI''''''''''' _\.. ('~ A . ty.) (i-c;" c-.~ \.. b."", ),- J ~.\- *,'1 C v-e-- Co t..c- 17...- Time of Occurrence: \ \ S'\) ~"'-- a.<l :f6'<Y'- '^ t: 1+ "":) , . bvu1..1 \ .i.d f "..-~+ \J,I)"d, hill.J. U n...I. In t< ty1I<<....J 4. General description of the indebtedness, obligation, injury, damage or loss incurred so far as you now know. I\jtP, r! Page 1 of4 5. The name or names of the public employee or employees causing the injury, damage, or loss, if known. /1/,1.1+ 6. If amount claimed totals less than $10,000: Provide the amount claimed if it totals less than ten thousand dollars ($10,000) as of the date of your claim, including the estimated amount of any related potential future injury, damage, or loss, insofar as it may be known as of the date of your claim, together with the basis of computation of the amount claimed (include copies of all bills, invoices, estimates, etc.) Amount Claimed and basis for computation: C'~ ( : G~. ~ ~ 1?~~J d1~ 1'~~/:!:>YJLI'/V I If amount claimed exceeds $10,000: If the amount claimed exceeds ten thousand dollars ($10,000), do not provide a dollar amount In the claim. However, your claim must indicate whether it would be a limited civil case. A limited civil case is one where the recovery sought, exclusive of attorney fees, Interest and court costs, does not exceed $25,000. An unlimited civil case is one in which the recovery sought is more than $25,000. (See CCP ~ 86.) >? ~ -f.~ hlitJ/ <i- ? ~ Lf, 6_ o Limited Civil Case o Unlimited Civil Case You are required to provide the information requested above in order to comply with Government Code !j910. Additionally, in order to conduct a timely investigation and possible resolution of your claim, the Clt of Tustin re uests that ou answer the followin uestions, . 7. Name, address and telephone number of any witnesses to the occurrence or transaction from which the claim arises: jI/()~ 8. If the claim involves medical treatment for a claimed injury, please provide the name, address and telephone number of any doctors or hospitals providing treatment: IV~-v-- If applicable, please attach any medical bills or reports or similar documents supporting your claim. 9. If the claim relates to an automobile accident: Claimant(s) Auto Ins. Co.: Address: Telephone: Insurance Policy No.: Insurance BrokerlAgent: Address: Telephone: Claimant's Veh. Lic. No.: '-f V /3vv 6 \ '-I Claimant's Drivers Lic. No.: Iv' 8 7 7 9 7'1 '-- Vehicle MakelYear: 1f."J" /1z Ccr/ e!'i- Zo:.J 1 Expiration: If applicable, please attach any repair bills, estimates or similar documents supporting your claim. Page 2 of4 READ CAREFULLY For all accident claims, place on following diagram name of streets, including North, East, South, and West; indicate place of accident by "X" and by showing house numbers or distances to street corners. If City/Agency Vehicle was involved, designate by letter "A" location of City/Agency Vehicle when you first saw it, and by "6" location of yourself or your vehicle when you first saw City/Agency Vehicle; location of City/Agency vehicle at time of accident by "A-l" and location of yourseif or your vehicle at the time of the accident by "B-1" and the point of impact by "X." NOTE: If diagrams below do not fit the situation, attach hereto a proper diagram signed by claimant, CURB~ rt/Jf-/;' t2~(t... 1'1 SIDEWALK L \ C~-" PARKWAY SIDEWALK I ?-\- Warning: Presentation of a false claim is a felony (Penal Code ~72). Pursuant to CCP ~1038. the City/Agency may seek to recover all costs of defense in the event an action is filed which is later determined not to have been brought in good faith and with reasonable cause. 1 . /l I." /// Signature: /? /; / 4/; ,/. ~ /t / / Date: VZJ/o { Page3of4 IF LATE CLAIM: COMPLETE ITEMS 1- 9 AND THIS APPLICATION. SIGN BOTH FORMS. APPLICATION FOR LEAVE TO PRESENT A LATE CLAIM TO THE CITY OF TUSTIN The undersigned hereby applies for leave to present a late claim to the City of Tustin. This application is being made within a reasonable time, not exceeding one (1) year, after the accrual of the cause of action. Under some circumstances, leave to present a late claim will be granted (Government Code 9911.6). The reason for delay in presenting the claim is: Date Signature of Claimant Revised 12/2004 Page 4 of 4 INVOICE ~<'\ TU'-tTN. N'/fAW>IIJ() M"[z~r::. U ~" b/cf3/gG ,58 2 t. '2/"1- WO J~/ f-1/. rC/0,; / {/fJ 3. 77 f? PHONE N 1-7.,1( ,- 1'1' I DATE WANTED '. w.;;;~ I ~A I ~IOCENSENO ,1 SERIAL He I MOTORH('. I "lIL!AGE l 'A' 6,vc r {I . PARTS AND SUBLET AE"""'" LABOR 1M TERIALS WORK /" f-z {7f5j .,. f7.1c-Tl7N :!ffO Cf.3 1?'oular;1C { 8" 69 u ..hI!- --:7 ;as- ~ V/f}' - @ TUSTIN iii ACURA Kyle Herron Service Consultant Tustin Auto Center 9 Auto Center Drive Tustin, CA 92782 . Direct Line: (714) 734-4042 Fax: (714) 734-4045 Cell: (714) 240,3017 E-Mail: KHERRON@Tustinacura.com . TOTALS LABOR THII Ul'IMATlIlIAIED ON OUA INIPEC110N AND DOH NOT COYER ADOITIONAL PAATI OR L..A8OR PARTS AND MATERIALS {j. 7-? ,J- _IMY.__I\I'18O__....._..._.___.....STARTEO.WCflN SUBLET WORK lor> (/() OlI_PAIm__NOT_QIl_"'J:.I.clhIMY.~. ....TUlW.LV ntI_lICM11OT_1UCH ~ PAlm _IUUCT TO CIWlOI WITHOUT X, &Ib __ ntI_Tl__ _TlACCB'TNa...''- TAX ~ _ Al/lHC'llZED 8Y GRAND TOTAL /J1 ESTIMATE SHEET AND REPAIR ORDER ... ............... UhC). u.&A.