HomeMy WebLinkAboutMINUTES - 08211984 - 1.21 AMENDED CLAIM
CLAIM
BOARD OF SUPERVISORS OF CORrRA COSTA COUMTr CALIFORNIA
BOARD ACTION
Claim Against the County, or District ) 1VTI(E TO CGAIIMANr " August 21, 1984
governed by the Board of Supervisors, ) The copy of th s document ma ed to you is your
Routing Erk3orsements, and Board ) notice of the action taken on your claim by the
Action. All Section references are ) Board of Supervisors (Paragraph IV, below) ,
to California Government Codes ) given pursuant to Government Code Section 913
and 915.4. Please note all "warniegsn COunSel
Claimant: Robert Flaherty fy
Attorney: William E. Jageman
J U L 18 1984
Jageman & McGraw, Inc. CA 94553
Address: 303 Arlington Ave., Suite B Martinez.
Kensington, CA 94707 Via County Counsel
Amount: $500,000.00 By delivery to clerk on July 13. 1AR4
Date Received: July 13, 1984 By mail, postmarked on
I. Fim Clerk of the Board ot Supervisors County Counsel
Attached is a copy of the above-noted claim.
Dated: July 13, 1984 J.R. OLSSON, Clerk, By Deputy
T Jolene Edwards
II. FROM: County Counsel T0: Clerk of the Board of Supervisors
(Check only one)
�( ) This claim complies substantially with Sections 910 and 910.2.
( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are
so notifying claimant. The Board cannot act for 15 days (Section 910.8).
( ) Claim is not timely filed. Clerk should return claim on ground that it was filed
late and send warning of claimant's right to apply for leave to present a late
claim (Section 911.3) .
( ) Other:
Dated: By: ,,��� / Deputy County Counsel
III. FROM: Clerk of the Board 70: (1) County Counsel, (2) County Administrator
( ) Claim was returned as untimely with notice to claimant (Section 911.3) .
IV. BOARD By unanimous vote of Supervisors present
(X ) This claim is rejected in full.
( ) Other:
I certify that this is a true and correct copy of the Board's Order entered in its
minutes for this date.
Dated: a fq SG J. R. OLSSON, Clerk, By , Deputy Clerk
NTNG (Gov. Code Section 913)
Subject to certain exceptions, you have only six (6) months from the date of this
notice was personally served or deposited in the mail to file a court action on this
claim. See Government Code Section 945.6.
You may seek the advice of an attorney of your choice in connection with this
matter. If you want to consult an attorney, you should do so immediately.
. .V. FROM: Clerk of the Board TO: (1) County Counsel, (2) County Administrator
Attached are copies of the above claim. We notified the claimant of the Board's
action on this claim by mailing a copy of this document, and a memo thereof has been filed
and endorsed on the Board's copy of this Claim in accordance with Section 29703.
( ) A warning of claimant's right to apply for leave to present a late claim was mailed
to claimant.
DATED: J. R. OLSSON, Clerk, Byp Deputy Clerk
cc: County Administrator (2) County Counsel (1) 00031
CLAIM
RECEIVED
CLAIM AGAINST PUBLIC ENTITY NVO SSOBN
�;LERK BOARD OF SUPERVISORS
" NT A CO
2 I
4y STADeputy
Robert Flaherty hereby presents this claim to the
County of Contra Costa pursuant to Section 910 of the California
Government Code .
1. Name and address: Robert Flaherty, 3360 Camarones
Place, San Ramon, California 94583 .
2. The post office address to which Robert Flaherty
desires notice of this claim to be sent is as follows:
William E. Jagenman
Attorney at Law
303 Arlington Ave. , Suite B
Kensington, CA 94707
3 . On April L, 1984 on Highway 680 near Walnut Creek,
California, claimant received personal injuries and property
damage under the following circumstances:
Claimant was drivinc? his 1983 Chevrolet S10 pickup
truck southbound on Interstate 680 near North Pain in Walnut
Creek, California when another driver, Fred C. Martin, was
driving northbound in the southbound lanes and collided head on
with claimant. Negligent maintenance, design and planning and
construction on the part of the County of Contra Costa allowed
Pyr . Partin to enter southbound traffic by way, of an offramp and
thus be driving against traffic.
4 . As a result thereof, claimant received serious and
disabling injuries including but not limited to leg fractures
and lacerations and is still in Kaiser Hospital , Walnut Creek.
The extent of medical bills and wage loss is riot known at this
time.
5 . So far as is known to claimant he has incurred
damages in the amount of $5001 ,000 .00 for his injuries.
6 . The names of the public employees involved are not
known at this time.
7 . At the time of the presentation of this claim,
Robert Flaherty is still hospitalized and under medical care and
unable to accurately- compute his damages. Based on what is
known at the present time, damage of $500 ,000 .00 is claimed.
Dated: July 11, 1984
WILLIAM E. JAGtMi 4
Attorney for Robert Flaherty
i
00032
. CLAIM
BOM OF SUPERVISORS OF C1WM COSTA axygPy, CALIFOWIA
BOARD AL'1'ION
Claim Against the Canty, or District ) NOTICE TO CLAIMANT August 21, 1984
governed by the Board of Supervisors, ) The copy of this document.ma ed to you is your
Routing Endorsements, and Board ) notice of the action taken on your claim by the
Action. All Section references are ) Board of Supervisors (Paragraph IV, below),
to California Government Codes ) given pursuant to Government Code Section 913
and 915.4. Please note all "Warnings".
Claimant: Richard E. and Nada J. Lenz
20 Holly Lane County Counsel
Attorney: E1 Sobrante, CA
JUL 19 1964
Address:
Mertinez, CA 94553
Amount: Unspecified " By delivery to clerk on
Date Received: July 18, 1984 By mail, postmarked on July 17, 1984
I. FROM: Clerk of the Board at upervisors can y Counsel
Attached is a copy of the above-noted claim. Zajlz�g�
1984 J.R. OLSSON, Clerk tDated: July 18, , ByDe pu y
Jolene Edwards
II. FROM: County Counsel TO: Clerk of the Board of Supervisors
(Check only one)
(>�f This claim complies substantially with Sections 910 and 910.2.
( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are
so notifying claimant. The Board cannot act for 15 days (Section 910.8) .
( ) Claim is not timely filed. Clerk should return claim on ground that it was filed
late and send warning of claimant's right to apply for leave to present a late
claim (Section 911.3).
( ) other:
Dated: By. Deputy County Counsel
III. Elm! Clerk of the Board . TO: (1) ty Counsel, (2) Coe
ty Administrator
( ) Claim was returned as untimely with notice to claimant (Section 911.3).
IV. BOARD SER By unanimous vote of Supervisors present
(�() This claim is rejected in full.
( )
Other:
I certify that this is a true and correct copy of the Board's Order entered in its
minutes for this date.
Dated: i /g J. R. OLSSON, Clerk, By , Deputy Clerk
MING (Gov. Code Section 913)
Subject to certain exceptions, you have only six (6) months from the date of this
notice was personally served or deposited in the mail to file a court action on this
claim. See Government Code Section 945.6.
You may seek the advice of an attorney of your choice in connection with this
matter. If you want to consult an attorney, you should do so immediately.
. V. FRCM: Clerk of the Board ZO: (1) County Counsel, (2) County Administrator
Attached are copies of the above claim. We notified the claimant of the Board's
action on this claim by mailing a copy of this document, and a memo thereof has been filed
and endorsed on the Board's copy of this Claim in accordance with Section 29703.
( ) A warning of claimant's right to apply for leave to present a late claim was mailed
to claimant.
DATED: C / SL J. R. OI.SSON, Clerk, By �1l�LLo � , Deputy Clerk
00033
cc: County Administrator (2) County Counsel (1)
CLAIM
.. .___. .____._... .n=ate_..:._....•...as.r
CL, IM TO: BOARD OF SUPERVISORS .OF CONTRA COSTA COUNTY
Instructions ,�o Claimant
A. Claims relating to causes of ,action for death or for injury to
person or to personal property or growing crops must be presented
not later than the 100th day after the accrual of the cause of
action. Claims relating to any other cause of action mulct be
.presented not later than one year after the accrual of the cause
of action. (Sec. 911. 2, Govt. Code) r
B. Claims must be filed with the Clerk of the Board of Supervisors
at its office in Room 106 , County Administration Building, 651 Pine
Street, Martinez , CA 94553 (or mail to P.O. Box 911, Martinez, _CA) •
C. If claim is against a district governed by the Board of Supervisors ,
rather than the County, the name of the District should be filled in.
D. If the claim is against more than one public en+ '_ty, separate claims
must be filed against each public entity.
E. Fraud. See penalty for fraudulent claims , Penal Code Sec. 72 at end
'of this form.
RE: Claim by �tc?V7W fyz� ) Reserved Rfo erk' s filing stamps
411197M k),
RECEIVED
Against the COUNTY OF CONTRA COSTA) J.R`OLS 9E
ON
CLERK BOARD OF SUPERVISORS
or DISTRICT) T COSTA Co.
y
Fill in name ) er
The undersigned claimant hereby makes claim agains the C unty of Contra
Costa or the above-named District in the sum of $
and in support of this claim represents as follows:
--------------------------=---------------------------------------------
1. When did the damage or injury occur? (Give exact date and hour)
---- ------- - -T- . ----------------------------------------
�. ere id the damage o injury occur? (Include city and county)
3. -How did the damage or injury occur? (Give full ails, use extra
sheets if required) / _
------------------------------------------------------ --------------=--
4. What particular act or omission on the part of county or district
officers, ser ants or employees caus d the injury or damage?
5. . What are the names of county or district officers, servants or
employees causing the damage or injury?
6. What dot a or injuri 2do yo claim resulted? (Give full extent
of injuries or damages claim Attach two estimates for auto
damage)
7. How was the amount claimed a ove computed? (Include the estimated
amount of any prospective injury or damage. )
8. Name��sff and addresses of wi nesses, doctors a hospitals.
i7 _ e
�4zt�-
9. List the expenditures you made on account of this accident or injury
ITEM AMOUNT
a -
�. Govt. Code Sec. 910.2 provides:
• "The claim signed by the claimant
SEND NOTICES TO: (Attorne ) 'orb some person on his half. "
Name and Address of Attorney
Cla nt's SL9J ure
v. .
Ad re s
Telephone No. Telephone No. ova --.351-
d "`3 3
**************************************************************************
NOTICE
Section 72 of the Penal Code provides:
."Every person who, with intent to defraud, presents for allowance or
for payment to any state board or officer, or -to any county, town, city
district, ward or village board or officer, authorized to allow or pay !
the same if genuine, any false or fraudulent claim, bill, account, voucher,
or writing, is guilty of a felony. " . `
00*035
aF
iF * rounDERS
TITLE COMPOny
3000 Clayton Road,Concord,CA 94519 . . . . . . . . . . . . . . . 687-7880
577 Ygnacio Valley Road,Walnut Creek,CA 94596 . . . . . . . . 939-9010
2028 "A"Street,Antioch,CA 94509 . . . . . . . . . . . . . . . . . . 757-7300
12513 San Pablo Avenue,Richmond,CA 94809 . . . . . . . . . . . 233-8993
3685 Mt.Diablo Blvd.,Suite 110,Lafayette,CA 94549 . . . . . . 283-1711
368 Diablo Road,Danville,CA 94526 . . . . . . . 820-6660
675 Ygnacio Valley Rd.,Suite A-201,Walnut Creek,CA 94596 933-1031
821 Main Street,Martinez,CA 94553 . . . . . . . . . . . . . . . . . . 228-5511
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MUM
BOARD OF SUPERVISORS OF SRA COSTA COUrTPY, CA MnWIA
BOARD ACTION
Claim Against the County, or District ) NOTICE Tp CLAIMANT August 21, 1984
'governed by the Board of Supervisors, ) The copy of th s document ma ed to you is your
Routing Endorsements, and Board ) notice of the action taken on your claim by the
Action. AU Section references are ) Board of Supervisors (Paragraph IV, below),
to California Government Codes ) given pursuant to Government Code Section 913
and 915.4. Please note all "Warnings".
Claimant: Kenneth Howard Reed
901 Court St. (A Module, Room 14) County Counsel
Attorney: Martinez, CA 94553
Address: J U L 19 1984
M®ffinei, CA 04003
Amount: $150.00 By delivery to clerk on July 18, 1984
Date Received: July 18, 1984 By mail, postmarked on
I. FROM: Clerk of the Board ot Supervisors County Counsel
Attached is a copy of the above-noted claim.
Dated: July 18, 1984 J.R. OLSSON, Clerk, By Deputy
Jolene Edwards
II. FROM: County Counsel TO: Clerk of the Board of Supervisors
(Check only one)
( ) This claim complies substantially with Sections 910 and 910.2.
(;() This claim FAILS to comply substantially with Sections 910 and 910.2, and we are
��`` so notifying claimant.. The Board cannot act for 15 days (Section 910.8) .
( ) Claim is not timely filed. Clerk should return claim an ground that it was filed
late and send warning of claimant's right to apply for leave to present a late
claim (Section 911.3) .
( ) Other:
Dated: By: Deputy County Counsel
III. FROM: Clerk of the Board TO: (1) County el, (2) County Administrator
( ) Claim was returned as untimely with notice to claimant (Section 911.3).
IV. BOARD ORDEEt By unanimous vote of Supervisors present
(� This claim is rejected in full.
( ) Other:
I certify that this is a true and correct copy of the Board's Order entered in its
minutes for this date.
Dated: Cg" J. R. OLSSON, Clerk, By. , Deputy Clerk
SING (Gov. Code Section 913)
Subject to certain exceptions, you have only six. (6) months from the date of this
notice was personally served or deposited in the mail to file a court action on this
claim. See Government Code Section 945.6.
You may seek the advice of an attorney of your choice in connection with this
matter. If you want to consult an attorney, you should do so immediately.
V. FROM: Clerk of the Board ZOO: (1) County Counsel, (2) County Administrator
Attached are copies of the above claim. We notified the claimant of the Board's
action on this claim by mailing a copy of this document, and a memo thereof has been filed
and endorsed on the Board's copy of this Claim in accordance with Section 29703.
( ) A warning of claimant's right to apply for leave to present a late claim was mailed
to claimant.
DATED: 4,2 _ J. R. OISSON, Clerk, By �o ,u� � , Deputy Clerk
00030
cc: County Administrator (2) County Counsel (1)
CLAIM
` CLAIM TO. BOARD OF SUPERVISORS OF CONTRA COVA COUNTY
eturn origFnal application to:
Instructions to Claimant Clerk of the Board
P.O.Box 911
CaorniA. Claims relating to causes of action for death or b�nj;fijury to
person
person or to personal property or growing crops must be presented
not later than the 100th day after the accrual of the cause of
action. Claims relating to any other cause of action must be
presented not later than one year after the accrual of the cause
of action. (Sec. 911.2, Govt. Code)
B. Claims must be filed with the Clerk of the Board of Supervisors
at its office in Room 106, County Administration Building, 651 Pine
Street, Martinez, California 94553.
C. If claim is against a district governed by the Board of Supervisors,
rather than the County, the name of the District should be filled in.
D. If the claim is against more than one public entity, separate claims
must be filed against each public entity.
E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at end
of this form.
RE: Claim Py )R I I
iling stamps
JUL 1984
Against the COUNTY OF CONTRA COSTA)
J. R. OISSON
CLERK BOARD OF SUPERVISORS
or DISTRICT) CONTRA TSTA co.
. e
Fill in .name)..: ), g :,
The. undersigned claimant hereby° makes cI`iin against tikeuty gfp.Con r
Costa or the above-named District iri` the'✓sutn>
and. in support of this _claim regreents s° fnllowgs
1. When did the damage or injury occur?: (-Give° xat;tdtE� a' d Iour�'�
2. Where did the damage or injury occur?(Include city and-county
- - _�iU/�Cfi �.4�/-G�.�j�"�vG
3. How did the ftma a or injury' ? G�f - - --T-
g occur t 1 ulI details, use extra
sheets if required)
4. What particula act or omission on the part of county or district
officers, servants or employees caused the injury or damage?
00040(over)
..5. What are the names of county or district officers, servant's of
employees causing the damage or injury?
6. What damage or in7u es d you lam resulted? (Give full extent
of injuries or damages claimed. Attach two estimates for auto
damage)
7. How was the amo t claimed above computed? (Include the estimated
amount of any prospective injury or damage. )
--------------------------------------------------------------------------
------------------------------------------
8. Names and addresses of witnesses, doctors and hospitals.
9. List the expenditures you made on account of this accident or injury:
DATE ITEM AMOUNT
Govt. Code Sec. 910.2 provides :
"The claim signed by the claimant
SEND NOTICES TO: (Attorney) -- or by .sqme person on his behalf. "
Name and Address of Attorney.
Claiman s n ture
Addr ss
Telephone No. 'Telephone No.
-NOTICE
Section 72 of the Penal Code provides:
"Zvexy person vho, with intent to defxaud, presents #or -allowance or
for payment to any state board or officer., or to any county., town, city. .
district, ward or village board or officer, authorized to allow or pay '
the same if genuine, any false or fraudulent claim, bill, account, voucher,
or writing, is guilty of a felony."
00041
Cuum
BOAM OF SUPERVISORS OF CORTRA COSTA 0WRTY, CALIPCINIA
BOARD ACTION
Claim Against the Canty, or District ) VO!*ICE TO C[AIMWr August 21, 1984
governed by the Board of Supervisors, ) The copy of ths document ma ed to you is your
Routing Endorsements, and Board ) .notice of the action taken on your claim by the
Action. A11 Section references are ) Board of Supervisors (Paragraph IV, below),
to California Government Codes ) given pursuant to Government Code Section 913
`" and 915.4. Please note all "Warnings".
Claimant: Ron Padilla County Counsel
Attorney: Thomas Keiser, Esq. JUL 18 1984
9080 Telstar Ave. , Suite 301
Address: El Monte, CA 91731 Martinez, CA 94553
Amount: $100,000.00 -4` �� By delivery to clerk on
Date Received: July 16, 1984 By mail, postmarked on July 12, 1984
I. FROM: Clerk of the Board ot supervisors County CoLmsel
Attached is a copy of the above-noted claim.
Dated: July 16, 1984 J.R. OISSON, Clerk, By ao� Deputy
Jolene Edwards
II. FROM: County Counsel M: Clerk of the Board of Supervisors
(Check only one)
( ) This claim complies substantially with Sections .910 and 910.2.
( ) This claim FAIIS to oomply substantially with Sections 910 and 910.2, and we are
so notifying claimant. The Board cannot act for 15 days (Section 910.8).
( ) Claim is not timely filed. Clerk should return claim on ground that it was filed
late and send warning of claimant's right to apply for leave to present a late
claim (Section 911.3).
( ) Other:
Dated: 7/ By: Deputy County Counsel
III. FROK: Clerk of the Board TO: (1) Cam Counsel, (2) Canty Administrator
( ) Claim was returned as untimely with notice to claimant (Section 911.3) .
IV. BOARD ORDER By unanimous vote of Supervisors present
(� ) This claim is rejected in full.
(/ )
Other:
I certify that this is a true and correct copy of the Board's Order entered in irts
minutes for this date.
Dated: J. R. OLSSON, Clerk, ByWeL , Deputy Clerk
nr� SING (Gov. Code Section 913)
Subject to certain exceptions, you have only six (6) months from the date of this
notice was personally served or deposited in the mail to file a court action on this
claim. See Government Code Section 945.6.
You may seek the advice of an attorney of your choice in connection with this
matter. If you want to consult an attorney, you should do so immediately.
V. FROM: Clerk of the Board TO: (1) County Counsel, (2) County Administrator
Attached are copies of the above claim. We notified the claimant of the Board's
action on this claim by mailing a copy of this document, and a memo thereof has been filed
and endorsed on the Board's copy of this Claim in ac:oordance with Section 29703.
( ) A warning of claimant's right to apply for leave to present a late claim was mailed
to claimant.
DATED: J. R. CLSSON, Clerk, By, �Q/ ; Deputy Clerk
00042
cc: Canty Administrator (2) Canty Counsel (1)
CLAIM
THOMAS KEISER
Suite 301
9080 Telstar Avenue
El Monte, California 91731 -
(818) 571-6951
July 11, 1984 R Er,.--, E I V E D
Contra Costa County L
822 Main Street 1
P.O. BOX 911 J. R. OLSSON
Martinez , CA 94553 CLERK BOARD OF SUPERVISORS
yy c 11 RA COSTA, CO.
Bv...l.... ....... ...Deputy
Re: Claim of Ron Padilla
The following claim is submitted on behalf of Ron
Padilla.
Claim for Damages
Claimant: Ron Padilla
10638 Mulhall
El Monte, CA 91731
818/442-9747
Notice to be Sent To: Thomas Keiser, Esq.
9080 Telstar Avenue, Suite 301
El Monte, CA 91731
Date of Damage or. Injury: April 4,. 1984 on Highway 24 in
Walnut Creek, CA
How did Damage or Injury Occur: Driving truck from Antioch to
San Leandro hit bump or hole in road and bounced claimant up,
he hit head on ceiling of cab.
Treatment: Los Banos Community Hospital for emergency treatment,
then subsequent medical care by Dr. Kropac. Off work to date.
Witnesses: No witnesses.
Amounts Claimed: Off work since April 4 , 1984 .
Lost wages: Total unknown
Medical bills: Total unknown
Pain and suffering: $100, 000. 00
00043
w
Page Two
Please acknowledge receipt of this claim by returning
the enclosed copy of this letter with your date stamp.
Very tr yours,
THOMAS KEISER
TK/kt
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Claimant:
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RON PADILLA
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00044
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CLAIM 1-0-=�
BOARD C F SUPLRVISOM OF CORM COSTA COUR , QUXKFO IA
BOARD AMON
Claim Against the Canty, or District ) WMICE TO (TAIMANp August 21, 1984
governed by the Board of Supervisors, ) The copy of th s document ma ed to You is your
Routing Endorsements, and Board ) notice of the action taken on your claim by the
Action. All Section references are ) Board of Supervisors (Paragraph IV below),
to California Goverrment Codes ) given pursuant to Government Code!ion 913
and 915.4. Please nate all "Warnings .Cp n
Claimant: Deborah J. Ledesma 1/,
Attorney: 711 Talbart, #5 Martinez, CA 94553 Ma��4e go
1984
Y j C4
Address: �ss3
Via Health Services
Amount: $292.00 By delivery to clerk on July 18, 1984
Date Received: July 18, 1984 By mail, postmarked on
I. FTM: Clerk of the Board ot Supervisors y Counsel
Attached is a copy of the above-noted claim.
Dated: July 18, 1984 J.R. CLSSON, Clerk, By &LC- & Deputy
Jolene Edwards
II. FROM: County Counsel TO: Clerk of the Board of Supervisors
(Check only one)
This claim complies substantially with Sections 910 and 910.2.
( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are
so notifying claimant. The Board cannot act for 15 days (Section 910.8).
( ) Claim is not timely filed. Clerk should return claim on ground that it was filed
late and send warning of claimant's right to apply for leave to present a late
claim (Secticn 911.3) .
( ) Other:
Dated: 2� �' By: Deputy County Counsel
-- �y
III. FRCM: Clerk of the Board 70: (1) County Counsel, (2) County Administrator
{ ) Claim was returned as untimely with notice to claimant (Section 911.3).
a
IV. BOARD ODER By unanimous vote of Supervisors present
( ) This claim is rejected in full.
( )
Other:
I certify that this is a true and correct copy of the Board's Order entered in its
minutes for this date.
Dated: a�,l5794 J. R. OTISSON, Clerk, By , Deputy Clerk
� rsV laQ a--
VV MRNING (Gov. Code Section 913)
Subject to certain exceptions, you have only six -(6) months from the date of this
notice was personally served or deposited in the mail to file a court action on this
claim. See Government Code Section 945.6.
You may seek the advice of an attorney of your choice in connection with this
matter. If you want to consult an attorney, you should do so immediately.
V. FROM: Clerk of the Board TO: (1) County Counsel, (2) County Administrator
Attached are copies of the above claim. We notified the claimant of the Board's
action on this claim by mailing a copy of this document, and a memo thereof has been filed
and endorsed on the Board's copy of this Claim in accordance with Section 29703.
( ) A warning of claimant's right to apply for leave to present a late claim was mailed
to claimant.
DATED: (' 9 F4 J. R. aL.SSON, Clerk, By . Zg,,— dV.t.t�--t�a . Deputy Clerk
cc: Canty Administrator (2) County Counsel (1) 00045
CLAIM
r
CLAIM TO: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY
Instructions zo Claimant
A. Claims relating to causes of action for death or for injury to
person or to personal property or growing crops must be presented
not later than the 100th day after the accrual of the cause of
action. Claims relating to any other cause of action must be
presented not later than one year after the accrual of the cause
of action. (Sec. 911.2, Govt. Code)
B. Claims must be filed with the Clerk of the Board of Supervisors
at its office in Room 106, County Administration Building, 651 Pine
Street, Martinez, CA 94553 (or mail to P.O. Box 911, Martinez, .CA) ,
C. If claim is against a district governed by the Board of Supervisors,
rather than the County, the name of the District should be filled in.
D. If the claim is against more than one public entity, separate claims
must be filed against each public entity.
E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at end
of this form.
RE: Claim by ) Reserved for Slerk's filing stamps
Deborah Ledesma ) REC -,-117
VED
Against the COUNTY OF CONTRA COSTA)
) �. - lei . _ .
111��__:
1EE
or DISTRICT)
J. R. OLSSON
(Fill in name) ) KARD OF SUPERVISORS
'RA C STA CO.
The undersigned claimant hereby makes claim agai -9_ Contra
Costa or the above-named District in the sum of $ 292.00
and in support. of this claim represents as follows:
i. When did the damage or injury occur? (Give-exact date and hour)
June 19, 1984- 7:55 pm
1. Where did the damage or injury occur? (Include -city and county)
Contra Costa County-CCCo Hospital E Ward Parking Lot 2500 Alhambra Ave. Martinez
- - ------------------------------:---------------
3,--H-ow--did----the-----d-amage------or--injury occur? (Give full details, use extra
sheets if required) Patient came volunterally to Mental Health Screening at
the above address requesting hospitalization. Patient was interviewed, found not
to be in need of hospitalization and was told to return home and follow up with out-
patient treatment the next day. Patient left E Ward and proceeded to kick in the
passenger door of my car parked in front of E Ward.
--------------------------------------------------------------z---------
4, What particular act or omission on the part of county or district
officers , servants or employees caused the injury or damage?
Refusal of hospital admission to this patient was the singular cause
00046
(over)
s. What are the names of county or district officers, servants or
employees causing the damage or injury?
NONE
6 What damage or injuries do you claim resulted? (Give full extent
of injuries or damages claimed. Attach two estimates for auto
damage)
Extensive denting to passenger door of my car sufficient of require new door panel
and painting to match
-------------------------------------------- --------How was the amount claimed above computed? (Include the estimated
amount of any prospective injury or damage. )
See attached estimates
8. Names and addresses of witnesses, doctors and hospitals.
Thomas Lee. . . . . . . . . . . . . . ... .2500 Alhambra Ave. Martinez ( .1 Ward staff)
Leornard Maran. . . . . . . . . . . . .2500 Alhambra Ave. Martinez ( E Ward staff)
David Shaw. . . . . . . . . . . . . . . . .2500 Alhambra Ave. Martinez ( E Ward staff)
-------------------------------------------------------------------------
9. List the expenditures you made on account of this accident or injury:
DATE ITEM AMOUNT
NONE
Govt. Code Sec. 910.2 provides:
"The claim signed by the claimant
SEND NOTICES TO: (Attorney) or b some erson on his ehalf. "
Name and Address of Attorney /�i ,�
CIaiin ' S ' a re
711 'Talbart Stre t #5
Address
Martinez; Ca'. 94553
q �
Telephone No. Telephone No. .J YoZ-
**************************************************************************
NOTICE
Section 72 of the Penal Code provides:
"Every person who, with intent to defraud, presents for allowance or
for payment to any state board or officer, or to any county, town, city
district, ward or village board or officer, authorized to allow or pay
the same if genuine, any false or fraudulent claim, bill, account, voucher,
or writing, is guilty of a felony. "
00047
It
MARTINEZ POLICE DEPARTMENT CA00 1400 F - ft5 2.INCA -
13.CODE SECTION 4.CRIME ASSIFICATION 6.REPORT AREA
Gil
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110.VICTIM;,NAME 11.V'CTIM'S ADDRESS 12.HOME PHONE
'13.OCCUPATION AC 15.SEX 16.AGE 17.DOB 18.BUSINESS ADDRESS 18.BUS.PHONE
C��12 w 33 g-5 3')a-.03a5-1
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21.CODES FOR BOXES V=VICTIM W=WITNESS RP=REPORTING PARTY DC c DISCOVERED CRIME
ADDRESS CHECKED PERSON INTERVIEWED AGE] HOME ADDRESS TELEPHONE
C 1�t�^A� �A�i SPCA. `1}�1o►ti�AS �G' X500 r L �. vL 1 us - '�
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RES_ _
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-1).INDICATE WHO-CANIDENTIFY
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j V. = V(s--IM; W. = WITNESS. RV REPORTING PARTY, ETC.
(CENSE• STATE LIC.YR.IMAKE VEH,YR. MODEL TYPE� 'COLOR TOPIBOTTOM OTHER IDENTIFYING
JESCRIBE PROPERTY STOLENIDAMAGED MODEL NUMBERITYPE SERIAL NUMBER VALUE
1 N A S Sc�b�t2 DJ!
CACI r Gtw
152.MET INT OF EN Y C, „, 53. F WEAPONS' O E D >L E
)�o"o^ o ���PL� . r_C) i O �=Pl�uICA J .
55-TRAD RISO US ECT( ) jN�S-l}A{,FEAjU-RES OF;H RIM 0 RCAP 1<0 EG} i_FR�`�1-M�Tq�e1 F v�ly�c��`
56.NATURE OFF INJURY �`J V fV'�' S 5' WHERE TREATED\Il 1/ 58.AT(ENDING PHYSICIAN
CONTROLLED DOCUMENT
DUPLICATION OR REISSUANCE
CONTROLLED BY, LAW
Ral to `per 124
mw"Z?9" wt 00048
1 ES CASE NEED ADDITIONAL FOLLOW-UP?
- - - - -- .
S BY PATROL ❑YES BY INVESTIGATION 0 INACTIVATE QQ v7Jl�1 10 T- 4/ 14
,RREV
OFFICER'S DECISION REVIEwI OFFICER 6 NO. DAT
YES BY PATROL 0 YES BY INVESTIGATION 0 INACTIVATED 7": oZ0
6C ADDITIONAL Ff?'`" "-Uf BY PATROL
65.ADDITIONAL FOLLOW-UP BY INVESTIGATION
LISBON AUTO BODY
17 Gianini Road Phone (415)228-0310
FIT NF4 CALIFORNIA 84553 ESTIMATE Of REPAIRS
7—i�
NAME DATE
ADDRESS r PHONE
INSURED By ADJUSTER PHONE
Symbol FRONT Labor S Hbr.s. Poet Symbol LEFT Labor S Lb,- Ports Ss. ymbol RIGHT Labor S Mbr. Ports
Bumper
Bumper Britt. Fender, Frt. Fender, Frt.
Bumper Gd. Fender Shield Fender Shield
Frt. System Fender Midg. Fender Mldg.
Frame Headlamp Headlamp
Cross Member Headlamp Door Heodlomp Door
Stabiliser Sealed Beam Sealed Beam
Wheel 1 Cowl i Cowl
Hub Cap _+ Windshield Windshield
Hub A Drum Door, Front Door, Front a
�-
Knuckle
Knuckle Sup. Door Hinge Door Hinge
Lr. Cont. Arm-ShaftDoor Glass Door Glass
Vent Glass Vent Glass
Up. Cont. Arm-Shaft Door Mldgs. Door Midg.
Shock Door Handle Door Handle
Spring Center Post Center Post
Tie Rod Door Rear Door Rear
Steering Gear Door Glass Door Glass
Steering Wheel Door Mldg. Door Mldg.
Horn Rin i Rocker Panel Rocker Panel
Gravel Shield Rocker Midg. Rocker Midg.
Parking Light Floor i Floor
Frame Frame
Rod. Grille Dog Leg Dog Leg
Ouor. Panel Quar. Panel
Ouor. Mldg. Quar. Mldg.
Quar. Gloss Quar.Gloss
Fender, Rear Fender, Rear
Nome Plate Fender Mldg. Fender Midg.
Horn Fender Pad Fender Pad
Baffle, Side REAR MISC.
Baffle, Lower Bumper Inst. Panel
Baffle, Upper Bumper Brkt. Front Seat
Lock Plate, Lt. Bumper Gd. Front Seat Adj.
Lock Plate Up. Gravel Shield Trim
Hood Top Lower Panel Headlining
Hood Hine Floor Top
Hood Mid%, Trunk,Lid Tire %Wom
Ornament Trunk Light Tube
Rad. Sup. Trunk Handle Batter
Rod. Core Tail Light Point (7
Anti Freese Tail Pipe Undercoat
Rod. Hoses Gas Tank AUTHORIZATION FOR REPAIRS
Fon Blade I Frame I IYOU are hereby authorised to make the above specified
Fon Belt Hub& Drum repairs.
Water Pump Axle Signed
Motor Mrs. Spring GROSS PARTS
Clutch Linkage .......R DISCOUNT
NET PART
WREC SOd
, SALES TAX yv
MAKE0?2!
YEARSTYLE 6DEL Z ' C)n yv ns3v
-4
SERIAL NO. LIC. N0. .
D A MILEAGE GRAND TOTAL Z
A-Align N-New ON-Overhaul S-Sbalslbn or twit Material Subject to Price Change
!, SAFETY DIVISION
Y PERSONAL PROPERTY REIMBURSEMENT CLAIM
TO B% COMPLETED BY GLA1MA W:
Claimant 's Name: Deborah Ledesma Date: June 20, 1984
Address: 711 Talbart St. #5 Martinez
Department : ADAMH- Mental Health Screening Employee No: 35365
Describe the manner in which the loss or damage occurred: A patient came to Mental
Health Screening requesting hospitalization. Patient was in erview
ed and found not
in need f in- tient care and was gdvised to follow up with out-pt.
treatment the next day: Patient became very angry, exited ar
kick in the assen er door of my car parked in front of E Ward. Police were called,
patient was arrested and report filed. kSee attac e
Amount of Loss Claim $292.00
Amount to repair damaged property
(attach invoice b actual repair) $292.00
Original purchase price of article(s)
(attach sales slip on same) $not applicable
Where purchased: N/A
Date purchased: NIA
Do you carry private insurance coverage for property loss or damage to your \ersonal
property? Yes No XXX
If yes, have you contacted your insurance agent for reimbursement? Yes oI
If yes, how much did your insurance reimburse you for the claim? $
If no, why did the *company reject your claim? Not submitted to my insurance. No coverage
for damages to my car.
TO BE COMPLETED BY WITNESS Employee's Si ure Date
Confirming statement by witness to incident :
_4
1 `SL.d►Q V..q
1?7- a4�k�- 7K
0000
Witness' Name (Print) Signature of Witness