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Home My WebLink AboutMINUTES - 09171991 - 1.11 CLAIM 4. 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 September 17, 1991 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: $1,500.00 Section 913 and 915.4. Please note all "Warnings". QFt�F1�l�� CLAIMANT: DOSS, Roger AUG 2 6 1991 ATTORNEY: Date receivedOUNTY sa ADDRESS: 2819 Ruth Court BY DELIVERY TO CLERK ON AugustMA*JNt'IF Santa Clara, CA 95051 BY MAIL POSTMARKED: August 22. 1991 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. August 26, 1991 PpHHIL BATCHELOR, Clerk DATED: BY: Deputy 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: BY: AUJI Deputy County Counsel III. FROM: Clerk of the Board TO: County Counsel ('1) County Admin rator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). 1V. 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: SEP 17 1991 PHIL BATCHELOR, Clerk, By4,n". �� ,z , Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date thi�/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 1B; 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: S E P 19 1991 BY: PHIL BATCHELOR by Deputy Clerk CC: County Counsel County Administrator 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 ROGER DOSS RECEIVED ) Against the County of Contra Costa ) or - 2 3 1991 ) District) CLERIC 60ARD OF SUPERVISORS J Fill in name ) CONTRA CO T,5,CO. The undersigned claimant hereby makes claim against the' County of Contra Costa or the above-named District in the sum of $ i Snn nn and in support of this claim represents as follows: ------------------------------------------------------------------------------------ 1. When did the damage or injury occur? (Give exact date and hour) May 25 , 1991 2 : 00 P .M. ---------------------------------------------------------------------------------- 2. Where did the damage or injury occur? (Include city and county) (Brentwood) Discovery Bay Entra�,ce on the Delta Water i•n Contra Costa County 3. How did the damage _or injury occur? (Give full details; use extra paper if required) ;. SEE ATTACHED. ---------------------------------------------=-------------------------------------- 4. What particular act or omission on the part of county or district officers, servants or employees caused the injury or damage? RYcU Rod Carpenter Rammed the Jet Ski in a 5mph zone . He was riding in a Hard Shell Zodiac type boat . (over) 5. What are the names of county or district officers, servants or employees causing the damage or injury? 6. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage. A Kawasaki 550 J e t Ski 1987 (SEE ATTACHED ESTIMATES) -----------------------------------------------------4------------------------------ 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) To repair damage to J e t S k i ESTIMATED REPAIR AMOUNT - $1 , 500 . 00 ------------------------------------------------------------------------------- 8. Names and addresses of witnesses, doctors and hospitals. Barth Nelson , 91V F&'-f 001D 5�r.tniyi/gl� CIA , Roger Doss , 2819 Ruth Court Santa Clara , CA 95051 "61hey 577a5MYm o Y% C,T, ' &y,,v-rx 04. 9 4 5'/,/ ------------------------------------------------------------------- 9. List the expenditures you made on account of this accident or injury: DATE ITEM AMOUNT N/A Gov. Code Sec. 910.2 provides: "The claim must be signed by the claimant SEND NOTICES TO: (Attorney) or by someperson-or) his behalf." Name and Address of Attorney Claimant's Signature Address Telephone No. Telephone No. �D�� /3-U57>6 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. ATTACIIMENT 3,. We (myself and Barth .Nelson) were headed out of Discovery Bay towards fast water , traveling through a 5 mph zone on two Jet Skis . We were lying down supporting by our elbows with our legs in the water traveling 5 mph . I reached the 5 mph markers (Bouys) then turned to look for Barth and saw the boat ramming him and the Jet Ski . The Jet Ski went under water as the boat separated Barth from the Jet Ski . I returned to the scene to find Barth bumped and Bruised on the head and the left elbow and the Jet Ski was badly damaged . I asked Rod Carpente what happened , first he said , '"My throttle stuck" , then he said , "I was chasing you and didn ' t see him (Bdrth). We towed the Jet Ski to a dock to fill out an accident report and a witness stopped to see if we were OK and Rod Carpenter said , "I was trying to stop Barth" . . . . ? as he was explaining the accident to us and the witness. o a o � � 0� > > W p p i d� W U w cc i a (f� Z i p f o o N J a <. U) ¢ O .. i O� N N ElO Cl) ¢ >a J X FA J Q Q Q o m tr Q Q wY F U Q a J cr pa OF IW z z z F H W =F D ~ o a w^ 1 w w~ � C) 7J a I z ° D g, a ❑_ zo W w w w Y t o t g y o s a: c. ;m;V. � I a vnsod=ado L� V 3 co m=3u° Z °Tmcd=rbc _J Q LL mEcao_r10 -� Q Q - `� w O oma'a;i H;mew= w cc f z O Lo E= �w z � - I °nomomAo 0 0 a o i 1' Ei'mom5. m F lit tom L`moya .-�- ico •Z'1 r I w ¢ c nc r�dgD�� 4•• I 0 N p 03 "N° ,10 T N Y m° e 1 1'O ¢> Ea COON=O nota �01N-ma«C J < m moc_up d«u 41 2 IomoEEN°p O o o i >¢O ««omL3 z li L) a r zoo Z D I a i I c ................. . i - .. _........... 6 i i � I i . .I.....-i I . I ....I.... I i Ln CPI.... ......... ..... ..... 1... ... X =QN C ��IT Q a JtiM � J Y d¢LO 0 to w o t!! U- o v � �CLcc z g a.,a a 0 _ w z F } pz Q OYFtSZi-008+133tli 7101 ilON WYI oI'IL1I0 sF1�7"�I se3JV [ilF L7lgOtld • PERFORMANCE PAINT 1UO `4OUTH UM STREET SHEETNO._�OF--L-SHEETS UMMASr CA 85035 PHONE (508)2034NO DATE LAX.M NO.AL73W NAME I PHONE PHONE STREET l . CRY/STATE ' LP f� YEAR COLORCMAI(r� MOOEL` SSv REGISTRATION NO. SERIAL NO. LICENSE ODOMETEII, INSURANCE CO. ADJUSTOR r J 1�PAIF1 REPLACE D E S C R I P T 10 N LABOR LABOR PARTS AND SUBLET HOURS AMOUNT MATERIAL 2 4 v h 6 7 8 9 10 11 12 13 + 14 15 4 to 19 20 :L: � PARTS PRICES based on standard catalogue procurement PRICE LISTS subject SUB-TOTALS to CHANGE WITHOUT NOTICE.Procurement and delivery charges may be added for special service on items not available locally.DAMAGED or BROKEN parts ) w removed from car will be Junked,unless owner Instructs us otherwise in writing.If LABOR 2 / HRS.AT PER HR. - $ / 6 NEW PARTS listed herein or required are NOT available,we reserve the right to.. `v procure USED PARTS and/or REPAIR such damaged or broken parts,where $ Z 7s possible. the CHARGE for which will be made on an actual time basis at our = PIIRTS.LESS %ORI prevailing labor rete per hour.The above Is an estimate based on the inspection $ made.ADDITIONAL parts,or labor.may be required occasionally after the work f SUBLET 8 NET= has started,and opened up, as damaged or broken parts are then discovered ' - $ / c which were not evident on the fiat Inspection.SUCH ADORIONAL LABOR AND PAINT AND MATERIALS - MATERIAL WILL BE CHARGED FOR IN ADDITION TO THE ABOVE.ESTIMATE EXPIRES 30 DAYS AFTER DATE. SALES TAX - $ 1 ABOVE WORK TOTAL ESTIMATE - $ AUTHORIZED BYDATE TOWING-STORAGE ESTIMATE .Q G/ ADVANCE CHARGES - $ SUBMITTED BY WV (�^ DATE ` GRAND TOTAL •. �� " - 05 NOil Mr-4 iA JS f m � ' r ., .. %jp I ' VVI ' ` i . a .(05) c w � 0 cr —6 c fr6 J� � �. l�� P„ a s r �, �• �. � � � � �� .` 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 September 17, 1991 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: $115.00 Section 913 and 915.4. Please note all "Warnings". QK.:F--Ivrn CLAIMANT: FERRIS, Stephen AUG a 3 1091 ATTORNEY: Date received Auco r"eurP91 ADDRESS: 456 Robles Drive BY DELIVERY TO CLERK ON tAli Vallejo, CA 94591 August 21, 1991 BY MAIL POSTMARKED: I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. PPHHIL BATCHELOR, ClerrLoid4i..4912_� DATED: August 23, 1991 BY: Deputy 11. 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: 21111 BY: I �•� 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. qq Dated: SEP 17 1991 PHIL BATCHELOR, Clerk, By ��1�� .d/i I.I 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: SEP 19 1991 BY: PHIL BATCHELOR by l' Deputy Clerk CC: County Counsel County Administrator Claim b64. `' 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 ag in_st 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 St�� e. rr► 5 ) RE-CEGVE® Against the County of Contra Costa ) 1991 or ) AUG 2 2 District) CLERK BOARD 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 $ X115 and in support of this claim represents as follows: ------------------------------------------------------------------------------------- 1. When did the damage or injury occur? (Give exact date and hour) ----- 5 &----T v l y-11 Kq ------------------------------------------------------- 2. Where did the damage or injury occur? (Include city and county) n r A Q — Sa_Nab lo Ave,,.u.� (Orn�Y,7, Costa+ Cdr— /-Q W —A-tl'CLa �CC c�� rAr_, 11�i_tIS -------------4----------- ---------- ----------------- 3. How did the damage or injury occur? (Give full details; use extra paper if required) (• m� k;C �ccM Sia rcic�/5 /f7 0 ver /� le SVP�irCr�9s �rac�P t✓o f a 11"C. 0 r ^ / h,I w,r�S�ie.lc� . Qom c rs �e�e rcu,P �Vl a cv -zil�nh, _ sc�EP�S,C @ cL w�l�r.0 L �. °2 —Asa. �n=----------------------- J v 4. What particular act or omission on the part of county or district officers, servants or employees caused the injury or damage? f if ex �m^('(� /l e c� ��`q,,, !'d a c%woi v('S k a VP J/z ��c�.✓J /U d 52. 7A C If Ps K) f r r,d'r n 0 U e Ne C-aa,v/-epvl � V s LP. DUB �c�c A fl2 e6 a s��..r �G/�O� �� s inevr" (over)Ml'?a sum_ i V � � �� (�� J I f�� cyrD�a Cairo w�wd�l f. see�4k Sx,� /ate�r�e��sr� , . +-vf ithaA � a,"' y Ak4 r)v w�ed a,�o wqa 5� rKoff5. Wa are",t�� of nyford strictie4�, servants or emplo� yklausing, y the damage or injury? C d-v1 ko, (6 S4 C 0 v n� - �0 a 1 C c)'1 S JU ---------------------------- --------------------------------------------- --c-m-�,----- 6. What damage or injuries do you claim resulted? (Give full extent of Ynjuries ori damages claimed. Attach two estimates for auto damage. - --- �- -------�--------- -�Cbac C 10i d�4 ------Q/X K-----`Wj!- -0--a-s-v-r-.`-----p---co 7. - - How was the amount claimed above com�uted? (Include the estimated amount of any prospective injury or damage.) tIo-o is rl� Q �d��' wiy 8. Names and addresses of witnesses, doctors and hospitals. ----------CCe�- CO. f -S --------i h►v � C l --- -------f---- ----------- -- 9. List the expenditures you made on account of this accident or injury: DATE ITEM AMOUNT 164/I^_ AAA a 1 UY� t'h�(u c-0tn tih VL�W� U oh C w t V15V fa/KQ R'�� oy C v/ ettJA Gov. Code Sec. 910.2 provides: "The claim must be signed by the claimant SEND NOTICES T0: (Attorney) or by some person on his behalf." Name and Address of Attorney Ferris laimant's Signature �5 6 %06 Address q `� S ie ._ TL6.1c_w__c No 707— 6 V7, -316 2-6 1C1@�J�1Vi1@ �IV. � 1GlcF/liVilc: a. . N 0 T I C E Section 72 of the Penal Code provides: "Every person who, with intent to defraud, presentsfor 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)9 or by both such imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ($10,0009 or by both such imprisonment and fine. r. } LLI >JO W W r Oz m Z tCJ co its J J ° O W f x l>> ~ W U Z SCJ H D f` F- Q Q 0 U� J U� Z 5f! W Z 1- ri rl rl QJ a-I Z U { cu a W U�C7 I �1 waw p 4 W ! 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C c5� Lr) Cy N v � � Q.s o r 0 i i 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 September 17, 1991 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: $286.00 Section 913 and 915.4. Please note all $$warnings". • GI LBERT, Ronald J CLAIMANT: ATTORNEY: N AUG Z 6. 1 c ZpY Date received ADDRESS. 15263 Hes eri an Blvd. # �� BY DELIVERY TO CLERK ON August 23 COMY1COUNSE. ....•.. a---- San Leandro, CA 94578 t • BY .MAIL POSTMARKED: Unreadable I.. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. Oct August 26, 1991 EYIL BATCHELOR, Clerk DATED. . eputy 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 910.29 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: 2c. BY: Deputy Count Counsel P y y .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 C1aim'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. S . Ep 17 1991 PHIL BATCHELOR, Clerk, B Deputy Clerk _ y 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: P 19 1991 BY: PHIL BATCHELOR b De ut Clerk SE y P y CC: County Counsel County Administrator r ' 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-toper-, 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, atter'.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: aim By ) Reserved for Clerk's filing stamp �CCEIM oD Against the County of Contra Costa ) or ) AUG 2 3 District) Fill in name \, '. ) CLERK BOARD OF SUPERVISORS CONTRA COSTA CO d The undersigned claimant hereby, makes claim_ against the County of Contra os a the above-named• District,. in,the sum of.-'$ o de and in support of this claim represents as follows: 1. When did"the- damage or •injury occur?`••(Give exact date and hour) z Z-!/ z ------- ---- 2. Where did the damage or injury occur? (In lude city and cou ty) 71 ZO ds�* 3. How did the damage or injury occur? (Give full details; use extra paper if required) uC_ --------------------------------------------Pde? ----------------------------- 4. What particular act or omission on the pty or district officers, servants or employees caused the injury (over) 5. What are the names of county or district officers, servants or employees caus`�*ng the damage or injury? r 9 oA ---- ------------------------------------------ 5. What damage or injuries do you claim resulted? - (Give full extent of injuries or damages claimed. ttac aestimSs for auto damage---------------- ------------: l� 7. How wa . the amount 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 Gov. Code. Sec. 910:2 provides:. "The clai u be sig d y he claimant SEND NOTICES T0: (AttorneyY or b me s on a f." Name and Address of Attorney (Cl i is Signature // Addr 4Z /L '.Telephone"No. _ Telephone-No., 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 impr.isonment,,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. WIN to:kmitidd)IN II, I I'f i � RrEF. 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Z86»110 91-05944»9888 1: C4Id�€flS1iEt1�RE%EhfP�N4, I GU10ERh0�t11Xi,D,NO;�' ; arCODE t836lANlD, 6N8Y "1 1NSr�llEDBYEOEI�t�Kf�0,N0' �I � '. .I I' ..I,I: �� `.'t 't. I� .IJ,� '''t, �1 i� ,' •:.f4,. '� I:,r 1, ! ',•..' ,I '.�r� � '�1Nr1" .,.'. _. —. 1• j�+� I i; � � .i I I;I I I i I � �I r:;. �• t F III � ; II#;:j. I' 'I I�' I' .. Uf If i f 1, � `� �i!!I:,:r � I. III• � I I`, 'fi Ij. � �j� � iIi!',ri l' �I I. III I��.'':I,• i, � IJ- . ( , If t�i r' I' .Y CITIES: Ih NGE GQ, "a �Q'ICY W, AA j(j}� I• � �,I I i��• M+��. 1 �!r�w�w+�••ri�.r rn , I ((// ' ' J ' •I,i ''I f%411 It'CAN .ti �,�. •.•�.--+ '+:�.+w:....«....e •.'"'__—``-"_ 1 11 t bill.? L1 't$0 1. I t �.....r.+......» IIle41 I O��j� 11 11 j 'f: G6QUCf it - 1 t1lrr�e,Mesenllara it I ;'i; y1 ' `1111' /� � i!I i,{i•! (. , ; At i I I{I'i, '�. �'i��;� •�7�t t "�'^:►:t;7wrf•f•Rr.'='" J, I �I i' Ili I i �.{ �' ..I, Jill, . It ,I III + ,, 1: g, it I', .,t• _ ' j:7,I ! it I I jIT, 'j , :,, ',I f,y Iy�jr, jji:' I, ' it.,� �i l �,c f'cLlaes war`FiLFkNI iNaC�I ' jl Ii;ill , ,ti "Under me Mccn.nla'.Lron Lew tCerdomla Cpaa ar,Cmt PrdpPdD».SPaepgt.th at,eaa9.).wy a:'mnctar,wgeantree�aq,bMrcr, 'i j •li! � � �j� , P4QpilPr,pr ptt*ar petdan'whp hglp!ip Ime{p�rya�VP year properq bdt;le nm pNaYPr htP atprk a+euppRpit heP;e rlght+b an{o 44ee P�eim � � sD+Met your CYope!iy.Fh{P tR>j�m!lhet h'egd4't heerinp,yan!gJaperry cadtd M 1pid by a adp '8'0,004 CPSds of the e91P ttBP4 to"Illy ine IndebiPdntHP.7h PUt.1(il3pa`n eYfil if yaU hPW.pdIC:Y.aur o'Fn lantretipr th run,H tM evaaanereetor,Iehorer, ' � !:i i!t bt tl;ti d 1 i~E+,8' 4hG ar Neon.,11.11 VPPPId" ,'_ � � ,,i , (rr A s.t5% I, rc@:1 A4Tl�OP.12E 7HQ A all Huk*ROPK TO BE 00NQ j I;' as .44 1, I' ILII!Y!►�� '"� f I V ' I I,�� OI�Gr filly" AL93-19-1991 08:51 FROM LOF CENTRAL NO. CAL. TO 9348278 P.01 Ubbey-Owens-Ford Co. !S1 MATE `j Glass Centers IN ORDER lNV XCE MDA ESMAN PILI.. TO: E S T I M A T E EIVA 50LD TU ADDRESS MAKE/MOD ADDRESS V.I.N.# CITY,ST LICENSE f MILEAGE CLAIMANT SPECIAL INST DATE TIME WORK PHONE HOME PH CUSTOMER 0 INST# COMP.DATE TIME INS/Poo QUANTITY ITEM NUMBER DESCRIPTION UST PRICE SALE PRICE TX 1 W10268 DOMESTIC WINDSHIELD 218. 42 TX 1 LDWCASH LABOR-DOMESTIC W/S 2S. 00 2 UDW U-KIT DOMESTIC WINDSHI 19. 90 TX 1500 SERIES PICK. UP aym er,ence - 02 ------ -------------------- -------------- ----- ----------- T 1,kx 19. EES Balanct Total 282- 98 THIS IS NOT AN INVOICE - DO NOT PAY - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - INSURANCE COMPANY INFORMATION BELOW THIS LINE RANCE CO. AGENT NAME NAME ADDRESS ADDRESS ADDRESS ADDRESS CITY,ST CITY,ST PHONE# FLEET# PHONE# POLICY# I I CLAIM# INSURANCE DATE OF CAUSE OF VERIFIED BY LOSS LOW AUG-19-1991 08:51 FROM LOF CENTRAL NO. CAL. TO 9348278 P.01 740 Ubbey-Owens'FOrd Co. ES MATE 5 `j Glass Centers W ORDER INV ICE SA ESMAN BILL TO: E S T I M A T E oA SOLD TO ADDRESS MAKE/MOD ADDRESS V.I.N.0 CITY,ST LICENSE 0 MILEAGE CLAIMANT SPECIAL INST DATE TIME WORK PHONE HOME PH CUSTOMER• epSH INST w COMP.DATE TIME INS/PON QUANTITY ITEM NUMBER DESCRIPTION LIST PRICE SALE PRICE TX 1 W10CbS DOMESTIC WINDSHIELD 218. 42 TX I LDWCASH LABOR-DOMESTIC W/S 225. 00 121 UDW U-KIT DOMESTIC WINDSHI 19. 90 TX 1500 SERIES PICK UP ayrtlReference a------ -------------------- ------------- ----- ----------- T x 19. ES Balancts Tod 1 282- 98 THIS IS NOT AN INVOICE - DO NOT PAY. *** - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - S-50 ott) To INSURANCE - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - INSURANCE COMPANY AFORMATION BELOW THIS LINE RANCE CO. AGENT NAME NAME ADDRESS ADDRESS ADDRESS ADDRESS CITY,ST CITY,ST PMONE M FLEET it PHONE N POLICY# CLAIM N INSURANCE DATE OF CANSE Of VERIFIED 8Y LOSS Lc u O co c13 c 14 s • 1 .11 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 September 17, 1991 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: $849.37 Section 913 and 915.4. Please note all "Warnings". CLAIMANT: KINGSLEY, Erin ATTORNEY: _UUNIY COUNSEL Date received Tye ADDRESS: 343 Alexander Place BY DELIVERY TO CLERK ON Aug ,'L1"," 1 Concord, CA 94517 BY MAIL POSTMARKED: August 20, 1991 Certified P 686 937 582 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. August 23, 1991 PpHHIL BATCHELOR, Clerk DATED: BY: Deputy 11. 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: 2 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 �Q 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: SEP 17 1991 PHIL BATCHELOR, Clerk, By /��/►�y ,� I 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: SEP 19 1991 BY: PHIL BATCHELOR by J'kDeputy Clerk CC: County Counsel County Administrator Claim t6: 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 9..4553• 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 orm. RE: Claim By ) Reserved for Clerk's filing stamp EER//l/ A_'1A/4.5_1_Ems/ ) RECEIVED Against the County of Contra Costa ) or ) AUG 2 1 1991 District) CLERK BOARD OF SUFERVISORS Fill in name ) CO��TRA COSTA Co. The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District in the sum of $ 849. 37 and in support of this claim represents as follows: -------------------------------- -w_w-__M_--_---------w-----------------_---- 1. When did the damage or injury occur? (Give exact date and hour) .5/ATuRDi4 y, �c/(u5T 3 17 3 2. Where did the damage or injury occur? (Include city and county) �L A c K,ygwK Ro,+D 9-r h 1 1,09' J nA)Tier? c.&52-4 Co vAj-r y 3. How did the damage or injury occur? (Give full details; use extra paper if required) 4. What particular act or omission on the part of county or district officers, servants or employees caused the injury or damage? R. ICf l Xe 7 KEEP RoAO Wh y CL EA9 of bE,BR/S 8. Ah'_/LURE T PRa v1.pE STREET 1-/6117-iA16 Guyicf/ &OL " AGGo li/ beb, 415 l/V /Pog,D 7"v BE SEAN . (over) 5, What are the names of county or district officers, servants or employees causing the damage or injury? VAIJCNO kIAI ------------------------------------------------------------------------------------ 6. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage. Tv Cgi2 ------------------------------------------------------------------------------------- 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) /O. 0.0 To To C-1 C,q,e To .D,yIvY/L L E• e X X o N • `50 S. 0 8 T MRKE C199 -OAEXAT/aNAL . ESr/NtRTFD *334- 01 —lo- 1qE104/'e ISI/R e`/D/T/oNI.✓G. ------------------------------------------------------------------------------------- 8. Names and addresses of witnesses, doctors and hospitals. ��AcICNRwK lq4/cE aFFic�i2- 1�tuLHvQ� (,64G -244() l9 I✓c A-55157W V6 0 ,4r-rC e 7W,— AGC/DENT. ------------------------------------------------------------------------------------- 9. List the expenditures you made on account of this accident or injury: DATE ITEM AMOUNT '? 9/ 5,1AJ T,4M„ti/ To ccJ X20/l0 9 ,� /0. .00 S- T-17/ DRNv/LLE EXX oN # 435 3 So °$ Gov. Code Sec. 910.2 provides: "The claim must be signed by the claimant SEND NOTICES TO: (Attorney) or by some person on his behalf.” Name and Address of Attorney �1 ,0J (.DK K/it/GSL6 yI F, 7,11.4 of Cl i s Signature fR/N XW4$16 y) 343 A•��XRNo�� Address C�AYToN, C4 945/ ,DA y C415) 17o57- 3394- Telephone o.s- 3394Telephone No. j Telephone No. EVe• C'4i 5) 67Z-62+Z- NOTICE 7Z-62¢ZNOTICE 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. Attachment 1 Question 3 "How did the damage or injury occur?" Answer I was driving toward Blackhawk on Blackhawk Road, near the entrance to Hidden Oaks at 9:30 p.m., on Saturday, August 3. There are no street lights and it was dark. I was driving at or below the speed limit when I came around a curve. The headlights of an oncoming car and the absence of street lights prevented me from seeing a large piece of a tree, which was in the middle of the roadway. I was not aware of the tree until I felt my car hit it, going through the front end and through my radiator. I was able to pull the car to the side of the road and I went to the guard booth at Hidden Oaks to get help. Police Officer Mulhurn (phone 646-2441) of the Blackhawk Police offered assistance. Shortly after the accident, around 10:15 p.m., a man arrived in a truck for the purpose of removing the tree from the roadway; I told him that it was no longer on the road, because I had hit it. AdOO a3WO1SnO 1 cY) M O Lo C'') ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ J J^, r = w ¢ aI O z o a� L p `o a J ¢ a o d m d v d m d O w V m ¢ v� LL J r J u m rn rn d m m E v c o p Q r ed x co w H O C C C" G V N d Y ^" r ¢. J m m uc { r0 J U ULL Ua Ur V] Ucn ?i mr am ¢LL oa p as as C1 `o_�s�El v m -du r m I, E w U o ax02w r - o ¢ • — -' O J U > a p w O f Z Z Ir oF' a a w ¢v z Z �E 9 o m ¢ o 0 3 3 vi JU Z Z V r \ o E c Q R o Y U U T"� j a 3o�8a = w Z _i w M ++tn m U m O U Ofl 4v�mo Zp �/ry� n� v• S -3„uFi �- m FTNw _ ' ❑ El ❑ vUgo_ Ep�^QaSoii_adiz r r Z U �j a a or J o 00 Cd �j O U1 J s Q OM LL, A ^p � A z ¢ ¢ r F w w a w w MJ ti�a �.U0 L'iW 0 0 V pH r Q o Qp ap aa 9 w<oa> � pD Z ND a W ¢ win w W LL a S o O F Q � Z C7 � CID O 3 \ ” cc ¢ � w Lu m r W3my u O ¢ W U) N �H a cr U) J r ww J = F Z �E m 3 LuW — $o co 2 — a z Z LU QW O O .Y I I I I I I I I I+1----I----EN I I I I a ' J J Q CHUCK PATTERSON'S TOIPOTA DODGE MAZDA DAIHATSU ' ESTIMATE • 200 East Avenue • Dial 895-1771 CHICO, CALIFORNIA 95926 OF REPAIRS SHEET No. OF SHEETS NAME ATE �dUG�� ADDRESS O O�ze y eon f ��PHOy D�—/ 7_ — YE MAKE MODEL LICENSE No. SPEEDOMETER VIN NO. 2,5W INSURANCE CARRIER ADJUSTER PAINT NO. MODEL NO. L R R FLAT ALL'D '.E E . DETAILS OF REPAIRS AND REPLACEMENTS PNT. RATE LABOR PARTS OR SUBLET P P. N:NEW U:USED AM:AFTER MARKET HRS IN HRS. IN HRS. MATERIAL xo/ 6-- `/ 04 9 2-F—, 2 151- a 6 J /20 3 4 4 12. S c, 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 TOTALS INSURED PAYS$ INS.CO. PAYS$ R.O. NO. / d O u v Labor « �� $�a INS.CHECK PAYABLE TO The above is an estimate,based on our inspectio�do6s not cover a itional parts or labor which may be Paint i $ required after the work has been opened u ccaslonally,after work has s rted,worn,broken or damaged Net Parts $ parts are discovered which are not evide t on first inspection.Quotations on parts and labor are current and � � subject to change. This estimate beco es null and void upon receipt of i surance Adjusters appraisal-of Tax��% �7�5 $�� 7 damages ESTIMATE MADE BY Sublet $ �r / Authorization For Repairs. You are he thorized to make the above specified r_ep_airs-to— the car described herein. Adv.Charges $ t' SIGNED DATE 19 TOTAL $ .7— Reynolds+Reynolds Ur 1.1uSA GPS-026299 GOOD FOR 180 DAYS FROM DATE OF ESTIMATE i ` vv � � kvti�w u !� !Zia�} ^+ } ° 1 .•.M V 05 01 R r fiC� 0 CCS . m N ul � U 4.4ccl -0 UU `° ci ! N O O W Nb � � U Sr U �;M 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 September 17, 1991 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: $160.00 Section 913 and 915.4. Please note all "Warnings". Rr%;EIVED CLAIMANT: MACK, Laura M. ATTORNEY: AUG ) 3 1091 Date received ,AUNTY COUNSEL ADDRESS: 1245 Greenview Court BY DELIVERY TO CLERK ON Au'' T'1f;u11'991 Martinez, CA 94553 Hand delivered BY MAIL POSTMARKED: 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. ppHHIL BATCHELOR, Clerk DATED: Augur 23. 1991 BY: 3�_ OV39 Of I_Aj� 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: 123 3 111 BY: Deputy County Counsel 111. 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. i A I /f Dated: 17 SEP 1991 PHIL BATCHELOR, Clerk, By �i,WtsaL� X�.til , 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 1 deposited in the United States Postal Service Iin Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. JLDated: S E P 19 199 BY: PHIL BATCHELOR by f Deputy Clerk CC: County Counsel County Administrator I 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 1OCth 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 ,aura, LYJ . ✓�'lac�� ) - �- � RECEIVED Against the County of Contra Costa ) or ) 2 � District) CLERK BOARD OF SUPERVISORS Fill in name ) CONTRA COSTA CO. The undersigned claimant hereby makes claim ainst the County of Contra Costa or the above-named District in the sum of $ M and in support of this claim represents as follows: ---=--------------------------------------------------------------------------------- 11:" When did the damage or injury occur? (Give exact date and hour) 4A, A14-C =� L� 00CL�_. --------------------------- 2. here did the damage or injury occur? (Include city and county) 3. How did the damage or injur c ? (Give full details;-use extra paper if required) ------ _491l- ----�------------------------------- 4. What particular act or omission on the p t of county or district officers, servants or employees caused the injury or damage? (ov.�r) 1 �. wnau are the names of county or district officers, servants or employees causing the damage or injury? ------------------------------------------------------------------------------------ 5. What damage or injuries do you claim resulted? (Give full extent of 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.) 8. Names and addresses of witnesses, doct rs and hospitals.--�1 � -Nv ° --------------------------------------------------------------------- ------- 9. List the expenditures you made on account of this accident or injury: DATE ITEM AMOUNT Gov. Code Sec. 910.2 provides: "The claim must be signed by the claimant SEND NOTICES TO: (Attorney) or by some person on his behalf." Name and Address -of -Attorney Claimant's Signature � kAddress Telephone No. Telephone No 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. ------ a,t, a�.�+-4c,:n y.� -_y3�.�-yam_ . --------- i ADDENDUM TO THE CLAIM OF l.��l�!� M • I lG�(ii` (Print your full name) ( 1) Do you use the roadway as part of a daily commute? Yes (�) No ( } ( 2) Were you aware that construction would be commencing on the roadway? Yes ( ) No ( 3 ) Was an alternate route available? Yes ( ) No ( ) ( 4) Did you read about the impending resurfacing in the local newspaper? Yes ( ) No ( ) ( 5) Did you see warning signs advising of loose gravel and a 25 mile per' hour advisory sign? Yes X) No ( 6) Did the damage result from another vehicle exceeding the 25 mile per hour advisory? Yes X) No ( ) (7) Did a vehicle traveling in the same direction and exceeding the 25 mile per hour advisory sign attempt to pass you? -Yes , (X No ( ,) ( 8) Did a vehicle coming from the opposite direction cause gravel to be thrown onto your car? Yes ( ) No ( X) (9) Was the vehicle located directly in front of you exceeding the speed advisory? Yes ('x) No ( ) ( 10). Did you travel the roadway more than once during the • resurfacing prior to the damage sustained to your car? Yes ( ) No (,><) ( 1.1) Did you obtain the identity of the car relating to questions 6 thru 9? Yes ( ) No If yes, please provide identification below: ( 12) 'Please describe in your own words how the gravel caused damage to your vehicle and the angle the gravel was thrown onto the car, along with the specific damaged parts on your vehicle. - 3 ( 13) Were you aware that using the road during the chip seal process might result in damage to your car? - Yes ( ) No ( ) "I declare that the above information is true and correct under the penalty of perjury. ( Signature) (Date) r,. -F,.. r•ai C:i l_.OH TO C:OHC:�RD F'.01 Co. g-IM-ATE rt E A T i M A T C DATS L� 9 ! I- -T �-LAYMAN` } SSP=r'ALfJS7 !DATE 14 V.11 C MT, 5 M _ C:MM ci1iE_� �—_--' - IZIPQr r�!!aA V i I*y !r �, w'i}1tj:h —� T JL.t=if�t:' _ r,T Pct-iw:��- F i i - SALE PHA F ----- 1� +�;� ��`� — DOMESTIC WINDSHIELD 112.3E i 1 t.DWCAEr+ LABOR-DOMESTIC WIC } a .00. UDW ( L-KIT 1)Ui1E2't IG WItIUSNI 1 iI ! � 4 # ..#�•v—.._.__ __ __._ � 4I)Ce PpkQ � 27� . Tan t Ql.09 0,riance Total 157.3fj *� !Hie r .; NOT AN TN01'TI;t JCl}SP:.r;',iNN0PifiAT ViY BE! b THUS L N, mpSs 0 t _ -- IAIJOREsS — -. i ht:+Cf w,%$ _ QTY.Sf ° _�_ �^ �`.�.,., IP«i.lA�_.�-.,._.�� --.-m..�. __ �FFt��-....-.....__ •FH{+"R7�� __.._..._-- ----.�_.-.-. ---...�. --- ..j kk IGY + j ISLAIN, I SAFELITE'Glass Corp. =j K2&JK3-F E=' SAFELITE AUTOGLASS QUOTE #: 10717 ORG DATE: 08-02-91 BAR#-AG 133972 08-02-91 10:08:01 BD 2049 CONTRA COST BVLD PLEASANT HILL, CA. 94523 INSURED LAURA MACK 415 687-7200 1245 GREENVIEW CT MARTINEZ, CA 94553 PHONE1 : 415-370-9328 PHONE2: CASH SALES - LOC 493 POLICY #: 2049 CONTRA COSTA BLVD CLAIM #: PLEASANT HILL, CA 94528 0000 AUTH/VER: / PO#/REF: LOSS LOC: 415 687-7200 LOSS DATE/CAUSE: 599898-000502-599898 PAGE 1 ================================================================================ YEAR MAKE MODEL MILEAGE LICENSE STATE VEHICLE ID NUMBER 1987 AMERICAN M GTA 2D COUPE STOCK #: ________________________________________________________________________________ QTY PART # LIST SELLING LABOR KIT MATERIAL EXTENSION 1 W950-S 280. 80 112. 32 40. 00 152. 32 NN SHADED WINDSHIELD NN � NN CL L) � � THIS IS A QUOTE ONLY. PART SUB TOTAL 112. 32 DO NOT PAY FROM THIS DOCUMENT. LABOR SUB TOTAL 40. 00 SUB TOTAL 152. 32 SALES TAX 9. 26 TOTAL ESTIMATE 161 .58 THANK YOU FOR CHOOSING SAFELITE FOR YOUR AUTOGLASS NEEDS ! =============INSTALLER INFORMATION============= |===========CLAIMANT============ IN-STORE NOT SCHEDULED | ADDRESS : | CITY : | WINDSHIELD REPAIR POSSIBLE YES NO | CUST INITIALS : ACCEPTEDDECLINED ------------------- ----------- CMT: ================================================================================ � ' _ SAFELITE'Glass� Corp SAFELITE AUTOGLASS ' QUOTE #: 10717 ORG DATE: 08-02-91 � - BAR#-AG 133972 . 08-02-91 10:08:01 BD � | 2049 CONTRA COST BVLD ' PLEASANT HILL, CA. 94523 INSURED LAURA MACK | 415 687-7000 1245 GREENVIEW CT MARTINEZ, CA 94553 PHONE1 : 415-370-9328 |� PHONE2: � CASH SALES - LOC 493 POLICY #: | / 2049 CONTRA COSTA BLVD CLAIM #: ! i � PLEASANT HILL,CA 94523 0000 AUTH/VER: / | PO#/REF: � LOSS LOC: | � 415 687-7200 LOSS DATE/CAUSE: � ! | 599898-000502-599898 PAGE 1 / ? | YEAR MAKE MODEL MILEAGE LICENSE STATE VEHICLE ID NUMBER 1987 AMERICAN M ,GTA ' ! 2D COUPE STOCK #: ' | QTY PART # LIST SELLING LABOR KIT MATERIAL EXTENSION 1 W950-S 280 80 112 32 4O 00 152 32 ' � ^ ^ ^ ^ L� SHADED WINDSHIELD \ , '� � � � '� Ti / i ` | | ' | | l ' . 1 ` , ^ �| THIS IS A QUOTE ONLY. PART SUB TOTAL 112, 32 .� | DO NOT PAY FROM THIS DOCUMENT. LABOR SUB TOTAL 40. 00 SUB TOTAL 152. 32 � | SALES TAX 9. 26 TO7Al. ESTIHATE 161 .58 ( |� THANK YOU FOR CHOOSING SAFEL1TE FOR YOUR AUTOGLASS NEEDS ! | j ' =============INSTALLER INFORMATION============= }===========CLAIMA��T============ IN-STORE NOT SCHEDULED | ! � '� ADDRESS : i `^ � ) CITY | WINDSHIELD REPAIR POSSIBLE YES NO | | -- -- F CUSTINITIALS : ACCEPTED DECLINED ------------------------------- | ------ ------ ! CMT: ================================================================================ | [" SAFELITE*Glass Corp, 't_ Sn' E: L 1 TE' ALI T OGLASS 000TE r o 0 7 17 0r 1)A T E o G a-0;2 -1 DAR"'-AG:--AC: 1 3q 72 os--02-91 p 10 I!0S e<_)1 {:3 0-49 CONTRA COGY DVLn 1111A., ;:A. 04323 "WSUREK) Lf LIRA I`riACI", <:15 E�t1-1._ x`00 y./;R!,,`j (}Ci"E%r�St1/l� :I.!c,CT I��yI1h7RT/.�-I\EZ, Cn 74•..1/5 143 PHCJNE I. i t110i3 lE"r-_'., CASH SALES -- LOC 40-3 PLP!...I C:Y _ 2'049 CONTRA COS T Ft L31...V'D rLAIiv1 V)a PLEASANT H I o.L,-C;,i 94523 0000 !;'(:] REI"„ 1._0- I_OC 4-15 687--1200 ':...C34?Ei DF4TF./t'';I YEAR MAKE 110DE':1. MILEAGE LICENSE: c'Cf-1TE: VLI-I""!.L ID i',:+(.;i-17D .h 1987 AMERICAN iii :•G`I`A i-?D COUP!w STOCK :? PITY PART I, LIST SELL NO LABOR' Ki CIl11t t A.L I' E_.��'SIrii"' %-IAD D WINDSHIf'.:L':D a N r n 0 n � THIS IS A [QUOTE. ONLY. FART 1-iUB TOTAL :1 2. DO NOT PAY F'ROf+! THIS LCIC:Ui}!1✓_NTo LABOIN ;.•UE: "f0"!'!al.., r:•G, 04; SUB T0"I'G!L 1 321, GALE i TAX TOTAL ESTI NATE 161 .58 - THAW YOU Fl.al: CHOOSING aF��F-E;LITE FOR YOUR t=IUTOGOLPsic;,S ivEr—P'i --•--•.-��:�::��:-:Iit!c�•Tf-IL!_.ER JIVE=17 W'.MAT':C71V:-�-:.------=-:_�.�.-=� 1 . -- ....__-_.�.:1..^'iMFII i'M..�-�-_.---::-_��:.::- IN-STORE NOT SCHEDULED I ADDRESS C!'TY . ! WINDSHIELD REPA I E: F=OSS I DI F, YES 1V0 i CLIS`i INITIALS AC:C;!:�F""!"F_D DEC:L.1►JE?� — _,..__.._..__.._._....___:_.---__..._. ..__..._._._.._.. ....._. 7' 0 0 W m 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 September 17 , 1991 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: $157 . 83 Section 913 and 915.4. Please note all "Warn4ngs". CLAIMANT: Fly pry PADGETT, Mary E. �' 1 ATTORNEY: AUG k' 0 Date received OOUN)N �tr ice`!'' ADDRESS: BY DELIVERY TO CLERK ON Aug its 9,ca A991 P.O. Box 1421 Lafayette , CA 94549 BY MAIL POSTMARKED: August 15 , 1991 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. PpHHIL BATCHELOR, Clerk v DATED: August 20, 1991 BY: Deputy __ 1AA2&314 V1 , 11. FROM: County Counsel TO: Clerk of the Board of Supervisors �J ) 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: 12G L9I BY:� S. /J Deputy County Counsel r 0 . :gLo_ 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: SFR 17 1991 PHIL BATCHELOR, Clerk, ByaL. ��L,�,t�' 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 io 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. SEP 19 1991 Dated: BY: PHIL BATCHELOR by Deputy Clerk CC: County Counsel County Administrator M "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 319 19879. 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.Ming stamp („ RECEIVED Against the County of Contra cc sta ) or ..._MG 1. 91991 (� � 8 RD OF SUPERVISORS V� Fill in name CO RA COSTA CO. U The undersigned claimant hereby makes claim against t County of Contra Costa or Q ,��# the above-named District in the sum of $ /5-/7. 3 and in support of . this claim represents as follows: ----------------------------------------------------------------------------------- 1. When did the damage or injury oc ur? (Give exact date and hour) - Cl I G'``"- I r �i G►�' sn:• --- --------------- "A- ------------=--=--- ----------------------- _--------------- ----------------- 2. Where did the or injury occur? (Include ,�d206cAran --------------- ------------------------------------------------------------------- 3. How did th ag or injury occur? (Give full details; .use extra paper if required) ` . . -7. C yyo,. eQ. ka cQ �o .::. c��. cv C)'. Q 12cQ., _b6 l m �,v . Cie Q ; Com �Q s � , aA�P_ ------------------------- 4. What partfcular act or omissio on the part of county or district officers, servants or employees caused the injury or damage? ' a Q CSL4 4� lJv'e�SZ `4cDo .Q CAJA Q d2 5. What are the names of county or district officers, servants or employees causing., the damage or injury? ---------- --------------------------------------------------=----------------- 5. What or injuries do you claim resulted? (Give full extent of injuries or damages claimed. • A tach- two a tjDaates, for auto d ________________ 7. How was the amount claimed above computed? (Include the estimated amo t, of any prospect've injury or de ) c, ------------------------------- ------------- -----------------------M------------ 8. Names and addresses of,witnesses, doctors liand hospitals. r OVk-O ------------------------------------------------------------------------------------- 9. List the expenditures you made on account of this accident or injury. DATE ITEM AMOUNT 0,. Gov. Code Sec. 910:2 provides: "The claim must be signed by the claimant SEND NOTICES TO: (Attorney.) or by some person on his behalf." Name and Address of Attorney.:;; VO imantls Signature Address T J � Telephone No. Telephone No. —� � (0 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, ". — -� U �ce�A oma-- i . ADDENDUM TO THE CLAIM OF1,� Print your full name) ( 1) Do you use the roadway as part of. a daily commute? Yes ( ) No (�) ( 2) Were you aware that construction would be commencing on the roadway? Yes No I ( 3 ) Was an alternate route available? Yes ( ) No ( ) ( 4) Did you read about the impending resurfacing in the local`s newspaper? Yes ( ) No �) ( 5) Did you see warning signs advising of, loose gravel and a 25 mile per hour n�hou,n,r advisory sign? �� GF"Cl�� v�.� tM.^Yes ) No l ) :- ah� ( 6) Did the damage result from anoth4vNic ext ee dijn ' t0 25 mil per hour- advisor c � SD �c l Yes , No ( ) (7) Did a vehicle traveling in the same direction and exceeding the 25 mile per hour advi ory sign at mpt to pas y Yes ( ) No ( ) <LAp, - ( 8) Did a vehicle coming from the opposite direction cause gravel to be thrown onto your car? r Yes ( ) No (.9) Was the vehicle located directly in front of you. exceeding the speed�orY�'?� \ � , ( 101 Did you travel. the .roadway more than once during the resurfacing prior to the dama e s staff ed to your car? cQa�,� �¢- o�c eth�.QcC tis `� � �e�,..�- � c� : ACV ( ) ( �) ( 11) Did you obtain the identity of the car relating to questions 6 thru 9? rujLu5 -if -So No yes, please ppron� �dQen /i^dentif/ilcat�io-n below. Ck qo -fes , . q-jD A-LYMAN, - -QA 12 Please - escrftio ownw�rds how the ravel caused ( } g damage to your vehicle and the angle the. gravel was thrown onto the car, along with the specific damaged parts on your vehicle. c lf-'L wm�( 13 ) Were you aware that using the road during the chip seal s might result in d age t your ar? 4 .-440. ' �� Yes ( ) No ( ) I dec are t`h"at the above nfor ation is trle ands correct . under the penalty o perjury. g t r e) G (Date) E� n C �Q�2 (, _ CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA F`T1%/FV Claim Against the County, or District governed by) BOARAc_41A the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT September-@a" and Board Action. All Section references are to ) The copy of this document mailed to you is AWIlWai f California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: $193.93 or $165.50 Section 913 and 915.4. Please note all "Warnings". CLAIMANT: SOUTHWICK, Marie ATTORNEY: Date received ADDRESS: 2437 Sullivan Street BY DELIVERY TO CLERK ON August 20, 1991 San Pablo, CA 94806 Hand delivered from Risk Management BY MAIL POSTMARKED: 9 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. August 21, 1991 ppHHIL BATCHELOR, Clerk o DATED: g BY: Deputy _ (3 FROM: County Counsel TO: Clerk of the Board of Supervisors J ) 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: 21 BY: / Deputy County Counsel III. FROM: Clerk of the Board TO: County Counsel (1) County Adminis or (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: SEP 17 1991 PHIL BATCHELOR, Clerk, By i ai. 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: SEP 1 9 1991 BY: PHIL BATCHELOR by Deputy Clerk CC: County Counsel County Administrator I 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 5911.2.) 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: C1aim. By ) Be r'ed o erk' iling t ) RECEIV Against the County of Contra Costa ) 2 0 1991 or CLERK BOARD QF SUPERVISORS �. District) CONTRA COSTA CO• Fill in name ) L The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District in the sum of $ 3 and in support of this claim represents as follows: 1. When 'did the damage or injury occur? (Give exact date and hour) -- 22. e di a damage or injury occur? (Include city and county) 3. How diddamage or injury occur? (Give full details; use extra paper if required ' � L 71 M--__-N- 4. at particular. act or omission..on the part of county or district officers, servants. or employees•eaused the -injury or damage?' (over) s �. wnat are the names of county or district officers, servants or employees causing the damage or injury? ------------------- ----------------------------------------------------------------- 5. What damage or injuries- do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for.auto damage. - ---- I----M--IIMIIMIIIIN----------N--MNMNM---N--N----N-----------IN---- 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) --M-M----I-NII---M----I--N--I--III--------------I-----III-I--II--M----I---II-II $. Names and addresses of witnesses, doctors and hospitals. INI-III------------ I..IIIII-IIIIII IIIrNII NIN----------------- 9. List the expenditures you made on account of this accident or injury: DATE .ITEM AMOUNT - Gov. Code Sec. 910.2 provides: "The claim must be signed by the claimant SEND NOTICES TO: (Attorney) or by some .person on his behalf." Name and Address of Attorney Claimant's Signature Address D�. Telephone No. Telephone No. /S—� 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. ADDENDUM TO THE C vU v LAIM: OF TT (Print your full name) ( 1) Do you use the roadway as part of a d ' ly commute? Yes ( } No ( ) ( 2) Were you aware ,that construction woul be commencing on the roadway? Yes ( ) No ( ) ( 3) Was an alternate route available? Yes ( ) No ( 4 ) Did you read about the. impending resurfacing in th local newspaper? Yes ( ) No ( 5) Did you see warning signs advising of loose gravel and a 25- mile per hour advisory sign? Yes ( ) No ( ) ( 6) Did the damage result from another v �icle exceeding the 25 mile per hour advisory? Yes ) No ( ) (7) Did a vehicle traveling in the same d' rection and exceeding the 25 mile per hour advisory sign a empt to pass you? Yes ( ) No ( ) (8) Did a vehicle coming from the ,.opposit direction cause gravel to. be thrown onto your car? Yes. ,( .. ) No (` ) ( 9) Was the vehicle located directly in front of you exceeding the speed advisory? _. Yes. ( ) No ( ) y ( 10) Did you travel the roadway more than once duririg 'the resurfacing prior to the damage susta' ned to your car? Yes ( ) No ( ) ( 11) Did you obtain the identity of the car relating to questions _6 thru 9? i Yes ( ) No If yes, please provide identification below: ( 12) Please describe in your own words how the gravel caused damage to your vehicle and the angle the gravel was thrown onto the car,, along with the specific damaged parts on your vehicle. 10, ( 13) Were you aware that using the road during the chip eal process might result in damage to your car? Yes ( ) No I declare that the above information is true and correct under the penalty of perjury. (Signature) (Date) MEL- 840-EL IS . Tf =ET •-SAN-FRAtVOIS , , _LIF M11 '(A 9 - 9- WARK Q R T 01t;-r e 1[ 8'32666 ' ' i I I a7t, =(BfU�64= 77; fit- j -6 360iIi roughout Cali or'n'a; . - L L �1_` TOSOL: C.C. O. D. ACCOUNT O Date 08-12-91 Insured's MARIE SOUTHWICK Name e Address City,State, Zip Code CITY STATE ZIP CODE Home — Work — Phone No. Phone No. Policy No. Date of Loss Reason for Loss Claim No. License No. Year-Make-Model 87 TOYOTA PICKUP Quantity Part No.&, Description ,List TOTALS .. 1 F471 S WINDSHIELD 299. 6 134. 82 134. 82 1 LABOR 35. 00 35. 00 1 KIT 12. 011 12. 00 TOTAL COST MATERIALS Req.From No. Date RELEASE AND AUTHORIZATION TO PAY OTHER THAN INSURED OR CLAIMANT SUB-TOTAL 181. 82 SALES TAX 12. 11 The glass has been replaced to my satisfaction and I authorize— LABOR to make direct payment to CENTRAL ALLIED (Non-Taxable) GLASS COMPANY the full amount due me under the terms of my policy covering the said loss. I understand that if for any reason my insurance company does not pay this claim, I BALANCE 193. 93 will be responsible for payment of same. LESS: DEDUCTIBLE 0. 00 Insured Date 30-200 THIS WORK HAS BEEN DONE TO MY SATISFACTION TOTAL 193. 93 MATERIAL NOT RETURNABLE WITHOUT PRIOR APPROVAL CUSTOMER COPY Pao e 1 12826 SAN PABLO AVENUE RICHMOND, CA 94605 Libbey-Owens-Ford Co. (415) 529.1991 ESTIMATE BAR *AL143548 WORK ORDER Glass Centers FED ID 0341506654 INVOICE SALESMAN 06 BILL TO: E S T I M A T E JDATE SOLD TOU45H-URY ADDRESS MAKE/MOD ADDRESS V.I.N.# CITY,ST LICENSE# MILEAGE CLAIMANT SPECIAL INST DATE TIME WORK PHONE HOME PH CUSTOMER# CASH INST# COMP.DATE TIME INS/PO# QUANTITY ITEM NUMBER DESCRIPTION LIST PRICE SALE PRICE TX 1 FCW471S FOREIGN WINDSHIELD 119. 84 TX 1 LFW LABOR-FOREIGN WINDSHIE 25. 00 1 UFW U-KIT FOREIGN WINDSHIE 9. 95 TX NOT INSURANCE RATE -C. O. D RATE ONLY Pay■t Reference Approval Date Amount Sub 154. 79 ------ -------------------- ------------- ----- ---------- Tax 10. 71 Balance Total 165. 50 ** THIS IS NOT AN INVOICE - DO NOT PAY *** - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - SOLD TO: x x X X X INSURANCE COMPANY INFORMATION BELOW THIS LINE I AN ECO. AGENT NAME MARIENAME ADDRESS e437 SULLIVAN STREET ADDRESS ADDRESS SAN CA 94806 ADDRESS CITY,ST _ CITY,ST PHONE# FLEET# PHONE# POLICY# CLAIM# INSURANCE DATEOF CAUSE OF VERIFIED BY LOSS LOSS /X 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 September �, X991 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: Unknown Section 913 and 915.4. Please note all "Warnings". RRT1VFD CLAIMANT: STATE FARM INSURANCE/BARNETT, Mary Claim # 05-0124-184 AUG Nr ATTORNEY: State Farm Insurance Companies 1090 LaPlaya Drive Date received COUNTY COUNSEL ADDRESS: Hayward, CA 94545 BY DELIVERY TO CLERK ON August 23,MAMYIZ' CALIF. BY MAIL POSTMARKED: Hand delivered from Risk Mgmt. I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. August 26, 1991 JAIL BATCHELOR, Clerk DATED: eputy (L II. FROM: County Counsel TO: Clerk of the Board of Supervisors ( ) This claim complies substantially with Sections 910 and 910.2. �(�y) 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: 2 G BY: 1 —Deputy County Counsel __0_ XJ 1I1. 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: SEP 17 1991 PHIL BATCHELOR, Clerk, By I 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. i Dated: S E P 1 9 1 1991 BY: PHIL BATCHELOR by4w Deputy Clerk CC: County Counsel County Administrator a NOTICE OF INSUFFICIENCY AND OR NON-ACCEPTANCE OF CLAIM State Farm Insurance TO: 1090 La Playa Drive Hayward, California 94545 Re: Claim of BARNETT, Mary Claim #05-0124-184 Please Take Notice As Follows : The claim you presented against the County of Contra Costa or District governed by the Board of Supervisors fails to comply substantially with the requirements of California Government Code section 910 and 910 . 2, or is otherwise insufficient for the reasons checked below: X 1 . The claim fails to state the name and post office address of the claimant. 2 . The claim fails to state the post office address to which the person presenting the claim desires notices to be sent . 3 . The claim fails to state the date, place or other circumstances of the occurrence or transaction which gave rise to the claim asserted. X 4 . The claim fails to state the name(s ) of the public employee(s ) causing the injury, damage, or loss, if known . X 5 . The claim fails to state whether the amount claimed exceeds ten thousand dollars ( $10 , 000 ) . If the claim totals less than ten thousand dollars ( $10, 000 ) , the claim fails to state the amount claimed as of the date of presentation, the estimated amount of any prospective injury, damage or loss so far as known, or the basis of computation of the amount claimed. If the amount claimed exceeds ten thousand dollars ( $10, 000) , the claim fails to state whether jurisdiction over the claim would rest in municipal or superior court . 6 . The claim is not signed by the claimant or by some person on his behalf . 7 . Other: VICTOR J. WESTMAN, C~ my Counsel By: I Deputy Co ty Counsel \1-*, CERTIFICATE OF SERVICE BY MA C.C .P. §!� 1012, 1013a, 2015 . 5 ; Evid. C. S§ 641 , 664 ) My business address is the County Counsel 's Office of Contra Costa County, Co. Admin. Bldg. , P.O. Box 69 , Martinez, California, 94553 , and I am a citizen of the United States, over 18 years of age, employed in Contra Costa County, and not a party to this action. I served a true copy of this Notice of Insufficiency and/or Non Acceptance of Claim by placing it in an envelope(s) addressed as shown above (which is/are place(s ) having delivery service by U.S . Mail ) , which envelope(s ) was then sealed and postage fully prepaid thereon, and thereafter was , on this day deposited in the U.S. Mail at Martinez/Concord, Contra Costa County, California . I certify under penalty of perjury that the foregoing is true and correct . Dated: at Martin , California. cc: Clerk of the Board of Supervisors o iginal) Risk Management (NOTICE OF INSUFFICIENCY OF CLAIM: G V.C.§,§ 910, 910 . 2, 920 . 4 , 910 . 8 ) STATE FARM State Farm Insurance Companies j INSURANCE g7 HAYWARD SERVICE CENTER August 7, 1991 1090 LaPlaya Drive Hayward, California 94545 Phone: (415) RECEIVED Contra Costa County 651 Pine, 6th Floor 1991 Martinez, CA 94553 AM 2 3 ATTN: RM HARVEY CLERK BOARD OF SUPERVISOR CONTRA COSTA CO.. RE: Our Insured : Mary Barnett Our Claim # : 05-0124-184 Date of Loss: 05-16-91 To Whom it May Concern: State Farm Automobile Insurance Company on behalf of subrogee, Mary Barnett, hereby makes claim for damages done to her vehicle when a hydraulic line broke and sprayed hydraulic fluid on her car regarding the above date of loss. 1. Notices concerning this claim should be sent to State Farm Insurance Companies, 1090 LaPlaya Drive, Hayward, CA 94545 referencing the above claim number. 2. The date and place of the accident giving rise to this claim are: on 5-16-91, on 2048 Herron Avenue in Walnut Creek, CA. 3. The circumstances giving rise to this claim are as follows: Our insured, Mary Barnett was operating her 1987 Ford Taurus vehicle when her car was sprayed with hydraulic fluid as a result of a hydraulic line breaking. 4. Companies net payment at this time is unknown. Insured's deductible interest is zero and total property damage is unknown. NOTICE: This form is to provide notice of our claim for damages in accordance with 100 day statute. If this form is not acceptable in compliance with the statute, please rush the necessary forms to the undersigned's attention for proper filing. HOME OFFICES: BLOOMINGTON, ILLINOIS 61710-0001 Thank you for your cooperation in this matter. V truly yours, 'A(A (A Tamra Brown Senior Claim Representative (415)847-3642 TB/kjh 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 September 17, 1991 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: $254.00 Section 913 and 915.4. Please note all "Warnings". CLAIMANT: TEIXEIRA, Don J. RE�KIY � ATTORNEY: AUG N 3 1991 Date received ADDRESS: 1371 Lexington Road BY DELIVERY TO CLERK ON AUguS�jjq��P� Concord, CA 94520 BY MAIL POSTMARKED: August 20, 1991 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. August 23, 1991 PpHHIL BATCHELOR, Clerk e DATED: BY: Deputy 1. 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: BY: Deputy County Counsel ul -/ III. FROM: Clerk of the Board TO: County Counsel (1) County Admi tr for (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:—SEP 17 1991 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: SEP 19 1991 BY: PHIL BATCHELOR by -Jj, Deputy Clerk CC: County Counsel County Administrator .. Clain 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_Pilin Tsp �nJ J iEc XC11Z/� ) E �C�d��® . Against the County of Contra Costa ) AUG 2 1 1991 or ) OARDOF SUPERVISORS District) .. r�T A coS7A Co. (Fill in name Y. The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District in the sum of $ 2 5+ tL and in support of this claim represents as follows: .w.YN-NMMN-NM-NM- NNMMN-N-MNNM-NM�M- �- 1. When did the damage or injury occur? (Give exact date and hour) Q G : 10 A Yy) 0,,J ry y Le a y To c.xnz►c N. S. F. w--N-Y�----M- 2. Where did the damage or injury occur? (Include city and county) f�'-K&"QsAnlT I-IfUL /2P. CcL>t T(-zA Cossnq Coin -�--..-N-N--�--N-N-- NM�M---NNS- M..---N--N�-M��-MN 3. How did the damage or injury occur? (Give full details; use extra paper if required). pc S C3RO�cCnl GJ�nl�sNlEtr� puE 7. t). Roci<s. 3 r=17_oM ?HC .LOSE 62/av_cr t_7y CR�l��. CON STRucTlON( - 13E0-IG --- N---------I.----rNN---N- 4. What particular act or omission on the part of county or district officers, servants or employees caused the injury or 'damage? NA zA 2 uk),Js rZoAO CLD.l'o i r-1un14s , (over) D. what are the names of county or district officers, servants or employees causing .. the damage or injury? ----------------------------------------------------------------------------------- 5. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage. CtAr S 1-J(N(P5H1C_.� 2ECC[�1 -0 . 3. CMAC -S. Du( Tv LC-)GsC= GrziaY�C Fr2or i ROAD .cx-45T2ucTr�r� -------------- ---------r-___-____-_______r---__r__-____----------------_------__---- 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) gvoTC s FftoM ..CZY AuT'o GCAJS Sh40P.S 4T711 c E4c- c s OAC C vvR Fin.. CAC.! F. C(AsS co.,._.- Z � TC; ' c)vuCAtLeo i v (3,y ,S FCC.A i rZ /�T� 6(A s) _M_ l"$ r�-W:✓R0 s%_ S).F..� 8. Names and addresses of witnesses, doctors and hospitals. __r-------------- __M_M__-___M___--------__-___M_M__----N_--__ 9. List the expenditures .you made on account of this accident or injury: DATE ITEM AMOUNT - r4or4e Gov. Code Sec. 910.2 provides: "The claim must be signed by the claimant SEND NOTICES TO: (Attorney) or byeme person on his behalf." Name and Address of Attorney ai 's Signature. 137 I GC x irl TU rf 20 , Address con/cs�2o CA Telephone No. Telephone No./41n 687-77++3 Wk 647- q*14 * * * 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 fora 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. HULi-19-1991 11:34 FPOH CALIFORNIA GDL SHI CO. TO 6474561 P.01 1090 Folsom Street Y Y'U MI 9M U�W California San Francisco, CA 94103 0 UJ U E U Glass Co. (415)255.9900 N`- ' 1609 NAME ` x-e' ra—, AODRE;;. RES.PHONE(( INSURANCE CO.IAGENT POLICY NO. ADDRf" YEAAR.MAKE.MODEL DELIVE%�piaEctIONS q I For 1 - O FURNISH d INSTALL SOLD eY CASH CH[CK CVD. CHARGE rN ACCT ❑FURNISH ONLY ❑WILL CALL ❑DELIVER QTY. SIZE DESCRIPTION AMOUNT (..t?. . ........_.. < ._.... I ...... ...... _ ce _ ! I _.... ......_...... . ... .... .-- - -._.. _. .. .......:......_........... ...............- -- ----- -.................._................. --._._ ._...-.._............................ ... .... ._.._..._ ... .. ... ..... ...........1.. ........... 1 DESCRIPnoN Or woAK I I ! I I TOTAL STATEMENT OF AUTHORIZATION AND SATISFACTION MATERIAL Replacement has DCen 1rado to my satisfaction and I hereDy TOTAL authorize the above inauranee Company to pay direct In full to the LABOR above listed firm for ss;o Installation.It for any reason the insurance ! Company does not pay for these repairs or replacements,the below signed agrees to pay for said repairs or replacement. TAX SUB-TOTAL I SIGNATURE o DEPOSIT =TOTA DATE I °� TOTHL P.01 r i c L � v W Z � � U w � � � Z � M 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 September 17, 1991 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: Unspecified Section 913 and 915.4. Please note all "Warnings". CLAIMANT: WEGRYN, Ted M. R��;E1Vgb ATTORNEY: AUG 2 0 1991 Date received ADDRESS: 17 Peggy Lane BY DELIVERY TO CLERK ON- ka p�+�1'0U11& 19 q I Martinez , CA 94553 MARTINEZ, GAAP BY MAIL POSTMARKED. Hand delivered I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. PPHHIL BATCHELOR, Clerk lal DATED: August 20 , 1991 BY: Deputy LZJ2, J 11. 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: BY:aA 4n 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: SEP 17 1991 PHIL BATCHELOR, Clerk, By AU1,41 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: S E P 19 1991 BY: PHIL BATCHELOR by A Deputy Clerk CC: County Counsel County Administrator 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. Y. RE: Claim By ) Reserved for Clerk's filing stamp RECEIVED Against the County of Contra Costa ) AUG 19 1991 or ) . District) CLERK BOARD 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 $ and in support of this claim represents as follows: -M---NO-N- 1. When did the damage or injury occur? (Give exact date and hour) Z1 { -! L:> P M MN---M--1-MM--M----NY--MM N--M----Nr-NM-------------M-N----M-- 2. Where did the damage or injury occur? (Include city and county) R C>04 6e;��.e.� c ;�,—ec� s C-�a.,oys� ('Zn Pr✓e�j� -----N----------�----- -------.. w -r---------------r-�-- N 1�..L 3. How did the damage or injury occur? (Give full details; use extra paper if required). �-D _M---M--M--�..------�---NM-M------NM--- --M---N-�-----r-M----NM-- 4. What particular act or .omission on the part of county or district officers, servants or employees caused the injury or damage? R P Ga. _-PL L,>ms's r3 Y-3 n- ra t , c C� ► i (over) r D. what are the names of county or district officers, servants or employees causing the damage or injury? 5. What damage or injuries do you claim resulted? (Give. full extent of injuries or damages claimed. ` Attach two estimates for auto damage. 1. ?:3 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) N--N---- -..- ---M-s----- $. Names and addresses of witnesses,- doctors and hospitals. 9. List the expenditures you made on account of this accident or injury: DATE ITEM AMOUNT - Gov. Code Sec. 910.2 provides: "The claim must be signed -by the claimant SEND NOTICES TO: (Attorney or 'b 'some erson on his behalf." Name and Address of Attorney Claimant's Signature ddress y.i Telephone No. Telephone No. 2 * * I V V I V I W. V V V 9,* .*. 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. J ADDENDUM TO THE CLAIM of (Print your full name) ( 1) Do you use the roadway as part of a daily commute? Yes No ( ) ( 2) Were you aware that construction would be commencing on the roadway? Yes ( ) No ( x) ( 3) Was an alternate route available Yes O< ) No ( ) ( 4) Did "you read about the impending resurfacing in the local newspaper? Yes ( ) No ( ) ( 5) Did you see warning signs advising of. loose gravel and a 25 mile per hour advisory sign? Yes ( �) No ( ) (6) Did the damage result from another vehicle exceeding .the 25 -mile per hour advisory? Yes (�) No ( ) (7) Did a vehicle traveling in the same direction and exceeding the 25 mile -per hour advisory sign attempt to pass you? Yes No ( ) (8) Did a vehicle coming from the opposite direction cause gravel to be thrown onto your car? Yes ( ) No (�) (9) Was the vehicle located directly in front of you exceeding the speed advisory? _. Yes (�,) No ( ) ( 10) Did you travel the roadway more than once during the resurfacing prior .to the damage sustained .to your car? Yes No ( ) ( 11). Did you obtain the identity of the car relating to questions•.6 thru 9? Yes ( ) No (�) If yes, please provide identification below: ( 12) Please describe in your own words how the gravel caused damage to your vehicle and the. angle the gravel was thrown onto. the car,. along with- the ' specific damaged parts on your vehicle. C21(- <- o �,� T Kc-:�) ,.-? p s N► L a I ? N �- ( 13) Were you aware that using the road during the chip seal process might result in damage to your car? Yes,( ) No ( j I declare that the above information is true and correct under the penalty of perjury. ( Signature) (Date) 1210 W WINTON AVENUE 100102901 HAYWARD, CA 94545 - � bo - 33 -611-1613 PC :LL TO: E S T I M A T E 08/07/91 CASH CASH 1. 00 FCW465S FOREIGN WINDSHIELD 392 . 25 205.93 TX 1. 00 LFW LABOR FOREIGN WINDSHIE 45. 00 1. 00 UFW URETHANE KIT 0. 00 0.00 TX i I I ymt Reference Approval Date Amount Subtotal 250.93 ---- --------------- ------------- ----- ---------- Tax 16.99 sh DEDUCTIBLE 0. 00 Total 267 .92 *** THIS IS NOT AN INVOICE - DO NOT PAY *** OLD TO: MR. WEGRYN 17 PEGGY LANE MARTINEZ CA 94553 I i V ,7rU4 c, w ~ P NS Q w Q U) U J Z GLO Q Cl) g \ O Q m Z r = CL m Cl Ci f o W a � i Lu w � CDrJ+ w O 0 uj O o cJ > Ll1 0 3 � 1 0 2 Y Q LU1�j W cc m z Cl) ki r� sJ Z U c!) CE Q w Z.6 a 0 I �.4 � �