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Home My WebLink AboutMINUTES - 07311990 - 1.14 (2) . CLAIMpp��..ee''11fRI BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CAL'I'FMMEC Claim Against the County, or District governed by) J U L 0 ti 199(12ARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT COU DU JULY 31, 1990 and Board Action. All Section references are to ) The copy of this documePll ftm4ft ou is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: $500,000.00 Section 913 and 915.4. Please note all "Warnings". CLAIMANT: PRZYMIERSKI, Kenith ATTORNEY: Sherrie L. McCracken, Esq. Law Offices Date received ADDRESS: 2938 Delta Fair Blvd. , #314 BY DELIVERY TO CLERK ON June 29, 1990 Antioch, CA 94509 Cert. P107 271 215 BY MAIL POSTMARKED: June 28, 1990 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. July 2, 1990 PpHHIL BATCHELOR, Clerk DATED: eputy II. FROM: County Counsel TO: Clerk of the Board of Sup visors 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. The 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: ��r) BY: )-' /. /JX Deputy County Counsel III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORD By unanimous vote of the 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: jt 31 C1D PHIL BATCHELOR, Clerk, By Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date 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. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: Q,(�,y1, 3 / 1470 BY: PHIL BATCHELOR by Deputy Clerk CC: County Counsel County Administrator a L ti J oe - v X ck) o � . 9 c.� 'OC1 d1s09�� slloswli3 ns ao GW xa313 0661 Z Z Nf1f a C13AI3038 ,- Claim to: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT A. Claims relating to causes of action for death or for injury to person or to per- sonal property or growing crops and which accrue on or before December 31, 1987, must be presented not later than the 100th day after the accrual of the cause of action. Claims relating to causes of action for death or for injury to person or to personal property or growing crops and which accrue on or after January 1, 1988, must be presented not later than six months 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. (Govt. Code §911.2.) 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. 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 the end of this form. RE: Claim By ) Reserved for Clerk's filing stamp KENITH PRZYMIERSKI � RECEIVED Against the County of Contra Costa ) or ) District] JCLERE, A CO SOBS Fill in name The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District in the sum of $ rnn ,onn _ on and in support of this claim represents as follows: ------------------------------------------------------------------------------------- 1. When did the damage or injury occur? (Give exact date and hour) 1-19-90 at 0720 ------------------------------------------------------------------------------------ 2. Where did the damage or injury occur? (Include city and county) BEAR CREEK ROAD APPROXIMATELY 2 , 534 FEET EAST OF CAMINO PABLO, ORINDA, CONTRA COSTA COUNTY ------------------------------------------------------------------------------------ 3• How did the damage or injury occur? (Give full details; use extra paper if requiredTWO VEHICLES, ONE DRIVEN BY CLAIMANT, APPROACHED A RISE IN THE ROADWWAY. CLAIMANT CAME TO A STOP , WAITED AND TURNED LEFT INTO THE PG&E DRIVEWAY. A VEHICLE DRIVEN BY THOMAS BEAN, APPROACHING FROM THE OPPOSITE DIRECTION CAME OVER THE RISE AND STRUCK THE RIGHT REAR OF CLAIMANT ' S VEHICI ------------------------------------------------------------------------------------ 4. What particular act or omission on the part of county or dist ict officers : THE PLACE servants or employees caused the injury or damage. MENT OF THE DRIVEWAY JUST BELOW THE CRES OF THE RISE IN THE ROADWAYCREATEI A BLIND ENTRY TO THE DRIVEWAY. THE RISE ITSELF WAS NOT A NECESSARY ITEM Ir ROADWAY: FAILURE TO PLACE APPROPRATE SIGNS OR ANY SIGNS INDICATING THE APPROACHING TRAFFIC AND BLIND SPOT. (over) 5. what are the names of county or district officers, servants or employees causing the damage or injury? UNKNOWN AT THIS TIME ------------------------------------------------------------------------------------ 6. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage. CAR DESTORYED:WAS BROKEN IN THREE PIECES : TOOLS AND PERSONAL PROPERTY, FRACTURED MANDIBLE, FRAC- TURED FRONTAL SINUSES, FRACTURED CHEEKBONES, FRACTURED SKULL, CONCUSS- ---------- 7. ONCUSS-----------ri7. How was the amount claimed above computed? (Include the estimated amount of any1ISC CU7 prospective injury or damage.) BRUISES,FACIAL MEDICAL EXPENSES APPROXIMATELY $30,000 . 00 and contin- SCARRING UING, # SURGERIES AND FACING ADDITONAL SURGERY AND MEDICAL BILLS, WAGE LOSS APPROX $15 ,000 . and continuing; automoblie destroyed , ---______- �_and-sit£fssax�gY- t� �nal_LlistYPS,��_JS2h_ rs�J.]? n requiredt_ loss 3. Names and addresses of witnesses, doctors and hospitals of occupation, future meds RONNIE ROBERTS 66 Leeward Way, Pittsburg, Ca; EDRR0Detfp'iR7LLTAAS, 5444 East 14th Street #A, Oakland; DAVID WAYNE, address unkown; THOMA! ALBERT BEAN III , 1101 Carey Drive, Concord; PAUL WILKINSON, 2617 S. Vasco Road , P. O . Box 351 , Livermore, California; see attached sheet ------------------------------------------------------------------------------------- 9• List the expenditures you made on account of this accident or injury: DATE ITEM AMOUNT MEDICALS approximately $30 ,000 and continuing AUTOMOB_V�I1a�E3 .�—.�'" UNKNOWN AT THIS TIME p _..�..d.� 9M SOWest Gov. Code Sec. 910.2 provides: ! "The claim must be signed by the claimant SEND NOTICES„TO;,; Jor by some person on his behalf." Name and Addres of II XSHERRIE L. MCCRACKEN, ESQ. LAW OFFICES' OF SHERRIE L. MCCRAC EN Claimant's nature 2938 Delta Fair Blvd . , #314 Antioch, California 94509 3018 Gratton Way, Concord , California Address Telephone No. Telephone No. xxxxxxx ni77 i 4 N O T I C E 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, city or district board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account, voucher, or writing, is punishable either by imprisonment in the county jail for a period of not more than one year, by a fine of not exceeding one thousand ($1,000) , or by both such imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ($10,000, or by both such imprisonment and fine. , CLAIM OF KENITH PRZYMIERSKI CONTINUANCE OF #8; witnesses , doctors, and hospitals JOHN MUIR MEDICAL CENTER, 1602 Ygnacio Valley Road , Walnut Creek DIABLO NEUROLOGICAL MEDICAL GROUP, 2121. Ygnacio Valley rd, Walnut creek ARTHUR CAREY, JR. M.D. P.O. Box 30187 , Walnut Creek, California SOSINE CHIROPRACTIC, 14510 Monument Blvd . , Dte 103 , Concord , California YIANNIS VLAHOS, D.D. S . , 3200 Lone Tree way, Antioch, California CARLOS DELGADO, 112 La casa Via, Ste 300, Walnut Creek, Calfiornia 5U.jdo j suilof S /1 Ul n • � r� V r � e ru '03 VIS03 VktL* SHOSIAHunsmo 0 v r ON691W, N co s (13AMM U. M G O d � N ' " CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFQ$pll LVED Claim Against the County, or District governed by) JUC BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT o ti 19MLY 31, 1990 and Board Action. All Section references are to ) The copy of this document }pd�o you is your notice of fti California Government Codes. ) the action taken on your 4EBoard of Supervisors F, (Paragraph IV below), given pursuant to Government Code Amount: $650,000.0 0 Section 913 and 915.4. Please note all "Warnings". CLAIMANT: ROBERTS, Ronnie ATTORNEY: Sherrie L. McCracken, Esq. Law Offices Date received ADDRESS: 2938 Delta Fair Blvd. , #314 BY DELIVERY TO CLERK ON June 29, 1990 Antioch, CA 94509 Cert. P107-271-216 BY MAIL POSTMARKED: June 28, 1990 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. DATED: July 2, 1990 EVIL BATCHELOR, Cler II. FROM: County Counsel TO: Clerk of the Board of visors 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. The 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: —441 2 1U BY: �- Deputy County Counsel III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER- By unanimous vote of the 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: 3/ mo PHIL BATCHELOR, Clerk, By Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date 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. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to,Claimant, addressed to the claimant as shown above. Dated: , ( G CIO BY: PHIL BATCHELOR by Deputy Clerk CC: County Counsel County Administrator v Claim to: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT A. Claims relating to causes of action for death or for injury to person or to per- sonal property or growing crops and which accrue on or before December 31, 1987, must be presented not later than the 100th day after the accrual of the cause of action. Claims relating to causes of action for death or for injury to person or to personal property or growing crops and which accrue on or after January 1, 1988, must be presented not later than six months 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. (Govt. Code §911.2. ) 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. 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 the end of this form. RE: Claim By ) Reserved for Clerk's filing stamp RONNIE ROBERTS > RECEIVED Against the County of Contra Costa ) E0290 or ) District) CLERK SWID OF SUPERVISORS Fill in name ) CONTRA COSTA CO. The undersigned claimant hereby•makes claim against the County of Contra Costa or the above-named District in the sum of $ 650, 000 . 00 and in support of this claim represents as follows: ------------------------------------------------------------------------------------- 1. When did the damage or injury occur? (Give exact date and hour) 1/19/90 at 0720 ------------------------------------------------------------------------------------ 2. Where did the damage or injury occur? (Include city and county)AINO PABLO, ORINDA, BEAR CREEK RAOD APPROXIMATELY 2 , 534 FEET EEAOF CONTRA COSTA COUNTY ------------------------------------------------------------------------------------ 3• How did the damage or injury occur? (Give full details- use extra nape required) TWO VEHICLES,ONE DRIVEN BY KENITH PRZY'MIERSKI , TN W I H CLAIMANT WAS A PASSENGUR, APPROACHED A RISE IN THE ROADWAY . PRZYMIERSKI AFTER COMING TO A STOP, ATTEMPTED TO TURN INTO THE PG&E DRIVEWAY. AVEHICLE DRIVEN BY THOMAS BEAN CAME OVER THE RISE AND STRUCK THE RIGHT REAR OF THE ------P27Y_MJZR.SKI_SLEHICL�------------------------------------------------------- 4. What particular act or omission on the part of county or district officers, servants or employees caused the injury or damage? DISCOVERY CONTINUING; THE PLACEMENT OF THE DRIVEWAY JUST BELOW THE CREST OF A RISE CREATED A BLIND ENTRY TO THE DRIVEWAY . THE RISE ITSELF IS UNNECESSARY: IMPROPER AND MISSING SIGNS WARNING OF DANGER TO TRAFFIC (over) 5. What are the names of county or district officers, servants or employees causing the damage or injury? UNKNOWN AT THIS TIME ------------------------------------------------------------------------------------ 5. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage. CLAIMANT SUFFERED INJURIES INCLUDING A 4-5 inch SKULL LACERATION, A CONCUSSION, DEEP PUNCTURE WOUN TO THE RIGHT BUTTOCK, RIGHT LEG, LEFT ARM, LOSS OF BLOOD REQUIRING 4 ------ BACK 7. How was the amount claimed above computed? (Include the estimated amount of any NECK prospective injury or damage. ) SHOULUER, MEDICAL EXPENSES APPROX $40 , 000 to date and continuing, LIMP loss of wages , pain and suffering, disfiguring scars , permanent limp, loss of occupation, job training required , future medicals , loss iouaL-list.mss----------------------------------------- 3. Names and addresses of witnesses, doctors and hospitals. KENITH PRZYMIERSKI 3018 Gratton, Concord; DAVID WAYNE, employee of Dave Tree address unknown; EDWARD LEE WILLIAMS , 5444 East 14th Street #A, Oakland , THOMAS BEAN III , 1101 Carey Drive, Concord , California;PAUL WILKENSON, 2617 S . Vasco Road , Livermore, Calif . ; JOHN MUIR MED CENTER, ______� tin2_yS�ria�jQ_y31y_gSL�_Tpj�111ib _�reekj_ NORMAN LIVERMORE,M_D__ P 0_Box 9. List the expenditures you made on account of this accident or injury: see attached DATE ITEM AMOUNT ..-...�......t.a..,�,,,,�...,�.e-ter MED` CALiSRI _ & 92 approximately $40, 000 .00 and continuing Med ' ca h r unknown Los o. Wages�1 approximately $15 , 000 .00 and continuing Gov. Code Sec. 910:2 provides: aacc SEND NOTICES TO; ttbrneya)j�aa= "The claim must be signed by the claimant or by some person on his behalf." Name and Address-of Attorney SHERRIE L. MCCRACKEN, ESQ. LAW OFFICES OF SHERRIE L.MCCRACKEN Claimant's Signature) 2938 Delta Fair Blvd .#314 Antioch, California 94509 66 Leeward EWay, Pittsburg, California Address (415 ) 778-4428 Telephone No. I Telephone No. xxxxxx N 0 T I C E 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, city or district board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account, voucher, or writing, is punishable either by imprisonment in the county jail for a period of not more than one year, by a fine of not exceeding one thousand ($1,000) , or by both such imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ($10,000, or by both such imprisonment and fine. 5. Wnat are the names of county or district officers, servants or employees causing the damage or injury? UNKNOWN AT THIS TIME ------------------------------------------------------------------------------------ 5. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage. CLAIMANT SUFFERED INJURIES INCLUDING A 4-5 inch SKULL LACERATION, A CONCUSSION, DEEP PUNCTURE WOUN TO THE RIGHT BUTTOCK, RIGHT LEG, LEFT ARM, LOSS OF BLOOD REQUIRING 4 ------ BACK 7. How was the amount claimed above computed? (Include the estimated amount of any NECK prospective injury or damage.) SHOULI5ER , MEDICAL EXPENSES APPROX $40 , 000 to date and continuing, LIMP loss of wages , pain and suffering, disfiguring scars , permanent limp, loss of occupation, job training required , future medicals, loss ------t -F _distrmss----------------------------------------- 8. Names and addresses of witnesses, doctors and hospitals. KENITH PRZYMIERSKI 3018 Gratton, Concord; DAVID WAYNE, employee of Dave Tree address unknown; EDWARD LEE WILLIAMS, 5444 East 14th Street #A, Oakland, THOMAS BEAN III , 1101 Carey Drive, Concord , California;PAUL WILKENSON, 2617 S. Vasco Road , Livermore, Calif . ;. JOHN MUIR MED CENTER, ______1�iQ2_yt�A3DjS2_yg1��X_Rd , � ia _� �el�j_ NQRMAN LIVERMORE �M_D__ P 0_Box 9. List the expenditures you made on account of this accident or injury: see attached DATE ITEM AMOUNT MEDICALr -: approximately $40, 000 .00 and continuing Medca,L unknown Losr oIF Wages ? approximately $15 ,000 . 00 and continuing * * * � SIM, * * * * * * * * * * * * * * * * * Gov. Code Sec. 910.2 provides: "The claim must be signed by the claimant SEND NOTICES 0:- -Ekt,15b^ney 1, or by some person on his behalf." Name and Address of Attorney SHERRIE L. MCCRACKEN, ESQ. LAW OFFICES OF SHERRIE L.MCCRACKEN Claimant's Signature) 2938 Delta Fair Blvd .#314 Antioch, California 94509 66 Leeward EWay, Pittsburg, California Address (415 ) 778-4428 Telephone No. 1 Telephone No. xxxxxx 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, city or district board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account, voucher, or writing, is punishable either by imprisonment in the county jail for a period of not more than one year, by a fine of not exceeding one thousand ($1,000) , or by both such imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ($10,000, or by both such imprisonment and fine. CLAIM OF RONNIE ROBERTS CONTINUATION OF #8 : WITNESSES, DOCTORS, HOSPITALS HOME MEDICAL EQUIPMENT, 1940 Olivera Street #C., Walnut creek, California§ NEUROSCAN, 115 La Casa Via , Walnut Creek, California KAISER PERMANENTE, Martinez , California ALAMEDA-CONTRA COSTA BLOOD BANK, P. O. box 2895, Oakland , California DR . GARRY, DR. KNIGHT, DR. HADDICK, P.O. Box 30187 , Walnut Creek, California I r I I i I r f .'A 4 1 i Ne- y Sys,•,.. V ,S� [`\�.�.�.� ,t* �? d �dS t3 ,Q y 'A v dQ _r c! ' - CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT JULY 31, 1990 and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: $1 , 000 . 00 Section 913 and 915 New, note all "Warnings". CLAIMANT: WILLIAMSON, Stanley B. JU[ 934 South 45th Street cOUN 1 1990 ATTORNEY: Richmond, CA 94804 '�4aTiN��Ng Date received ADDRESS: BY DELIVERY TO CLERK ON Julv 10 . 1990 . (via P .O. Box) BY MAIL POSTMARKED: June 28 , 1990 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. DATED: July 10 , 1990 �tlIL Bep�tyLOR, Clerk II. FROM: County Counsel TO: Clerk of the Board of Supervisors � ) 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. The 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: II to BY: � �, /J Deputy County Counsel III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the 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: 331. PHIL BATCHELOR, Clerk, By . Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date 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. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: 0JJri,, ta� 3, 1�19Q BY: PHIL BATCHELOR by Deputy Clerk CC: County Counsel County Administrator ^_LAIN% TC?- BOARD OF SUPERVISORS OF CONTRA a Vented ion to, `r' ' Instructions to Claima3A. Claims relating to causes of action for deathperson or to personal property or growing croped 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 mast be filed against eachpublic entity. E. Fraud. See penalty for fraudulent claims , Pen. ,l Code Sec. 72 at end o:: thi s form. RE: CC1aim lby .) Reserved for Clerk' s filing stamps I , ) _ RECEIVED Against the ='COUNTY OF CONTRA COSTA) O or DISTRICT) CLeRK80ARDOFSUPERVISORS (Fill in name) ) CONTRA COSTA CO. . The undersigned . claimant hereby makes claim against the Count pf Contra Costa or the above-named District in the sum of $ �dCb,_�4 and in support of this claim represents as follows : ---------------------------------- -------------------------------------- 1. When did the damage or injury occur? (Give exact date and hour) -------------- ---------------- --------------------------------------- 2. Where did the--- damage or injury. occur? (Include city and county) --------_._-__.:------- --------------------------- - - ow &id the damage or injury occur? (Give full details , use extra sheets if required) my - ��. . TH u. �a� A ,/rFX2-0® 4 it e C- teA 04 P00AA RUL % ; AL 4. Whatparticularact or omission on the-part of county or aistrict officers , servants or employee:; caused the injury or damage? F�data/ZC 1D (over) 5..:.:•f iat. ar.e.,the...names of county or district officers , servants or I employeescausing the damage or injury? -- ------------------------------------------------- ------------ 6. W - hat damage or injuries do you claim resulted? (Give full - extent f injuries or damages claimed. Attach two estimates for auto damage) 7 . How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage. ) Y �t � � UOH P J P N L t>, Fob *Th-E e S JI-J- ---------- ----------------------------------------------- . names a-nd aadresses of witnesses , doctors and hospitals. ---- -------------------------------------------------------------------- 9 . List the expenditures you made on account of this accident or injury: BATE s ITEM AMOUNT al ill . y9�5�'�nr� •`j1 Govt. Code Sec. 910 .2 provides : The claim signed by the claimant SEND NOTICES TO: ., (Attorney) or by some Gerson on his behalf. ' Name and Address of 'Attorney Claimant ' s Signature Address Telephone No. Telephone No. NOTICE Section 72 of the Penal Code provides : "Every person who ,. with intert 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 , anv false or fraudulent claim, bill , account , voucher or writing , is guilty of . a felony. " rh 1 v V ol dO, "t Z:S -... a ND t) QrZ cc S V f