HomeMy WebLinkAboutMINUTES - 10201987 - 1.16 CLAIM 6V
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 October 2 0, 1987
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: $103 . 56 Section 913 and 915.4. Please note all
CLAIMANT: MICHAEL A. KESSLER S-P � u 1987
2751 Broadmoor Avenue
ATTORNEY: Concord, CA 94520 1r , - 11 r, i`,
ZiDate received
ADDRESS: BY DELIVERY TO CLERK ON September 21 , 1987 hand del .
BY MAIL POSTMARKED: no envelope
1. FROM: Clerk of the Board of Supervisors TO: County Counsel
Attached is a copy of the above-noted claim. r =
PH gg
DATED: September 24, 1987 BYIL DeputyLOR, Clerk ;
L. Hall
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:
n �
Dated: 2�p � ,� J �� BY: Deputy County Counsel
J r�T
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
( w'J"/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: O C T 2 O 1987 PHIL BATCHELOR, Clerk, By l 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: O C T 2 11987 BY: PHIL BATCHELOR by
Vel��eputy Clerk
CC: County Counsel County Administrator
CLAIM TO: BOARD OF SUPERVISORS OF CONTRA COA Q99f;Xapplication to:
�y Instructions to ClaimantC!erk of the Board
P.O.Box 911
Martinez,Califomta94553
A. Claims relating to causes •of action for death or for injury to
person or to personal property or growing crops must be presented
not later than the 100th day after the accrual of the cause of
action. Claims relating to any other cause of action must be
presented not later than one year after the accrual of the cause
of action. (Sec. 911.2, Govt. Code)
B. Claims must be filed with the Clerk of the Board of Supervisors
at its office in Room 106, County Administration Building, 651 Pine
Street, Martinez, California 94553.
C. If claim is against a district governed by the Board of Supervisors,
rather than the County, the name of the District should be filled in.
D. If the claim is against more than one public entity, separate claims
must be filed against each public entity. .
E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at end
o his form.
RE: Claim by )Reserved for Clerk's filing stamps
RECEIVED
Against the COUNTY OF CONTRA COSTA) Si51° 11 1987
or DISTRICT) CL „K^"ID a, 1O" ,
(Fillin name Lh) A0O Ll-
J
The undersigned claimant hereby makes claim against the County of Contra
Costa or the above-named District in the sum of $ /0 3
and in support of this claim represents as follows:
�. When did the ry occur? (Give exact date and hour]
�. W�iere ��.d tie occur? (Include cit and county)
SCG S S
ss_ o cc/e� _
3. How did the y occur? (Giveu�I details, use extra
sheets if required)
O S `�
�--�-�-�'
1_
4. ,iha partictiar/ct o om ion o the part of1_co;--
nty or district
off cers, servants or employees caused the i^;,, y X damage?.
(over)
5. What are the names of county or district officers, servants or
employees causing the damage or injury?
_6/.1�14hLa/t damacsge_or/! nj_uL �es Cdo��l_e��u Ioc 'ti�m r�es%uBlStc?e ?� CiLvQe/. �u�ll �xZte;i ---
of injuries of damages claimed. . Attach two estimates for auto
damage)
t
------------------------ ------------------------------------------------
7. How was the amount cl imed above computed? (Include the estimated
amount of any prospective injury or damage. )
-------------------------------------------------------------------------
8. Names and addresses of witnesses, doctors and hospitals.
-- --------
T--err.-�-•.---T----�- -------------r�rT-----••--------T-T----
3. List the expenditurep you made on account of this accident or injury:
6 DATE '. ITEM AMOUNT
i
5
1
Govt. Code Sec. 910.2 provides:
"The claim signed by the claimant
SEND NOTICES TO: (Attorney) or by some person on his behalf. "
Name and Address of Attorney
C unant Sig ture
Addre s
Telephone No. Telephone No. (y/S� �n�'�/,s/
��:*:�**:��f*#tr*�*w***#���:�**t:�*:tit:w**�**�::�r•::*rr**tw*:*�t����:taw**
NOTICE
Section 72 of the Penal Code provides:
'Every person who, with intent to defraud, presents for allowance or
for payment to any state board or officer, ' or to any county, town, city
district, ward or village board or officer, authorized to allow or pay
the same if genuine, any false or fraudulent claim, bill, account, voucher,
or writing, is guilty of a felony."
�- CLAIM It/6
BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA
Cl'ai,;. Against the County, or District governed by) BOARD ACTION
the Board of Supervisors, Routing .Endorsements, ) NOTICE TO CLAIMANT October 20, 1987
.
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 , 145 . 00 Section 913 and 915.4. Please note all q&.Min4j.
CLAIMANT: JOHN V. LELAND S c P 't-). u 1,1087
P. O. Box 12002
ATTORNEY: Oakland, CA 94604 �:'r..-.:
•. ti{�li
Date received
ADDRESS: BY DELIVERY TO CLERK ON September 21, 1987 hand del .
BY MAIL POSTMARKED: no envelope
I. FROM: Clerk of the Board of Supervisors TO: County Counsel
Attached is a copy of the above-noted claim.
September 24 1987 �YIL BATCHELOR, Clerk
DATED: eputy
L. Hall
I1. 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: �„�_. f BY: ? Deputy County Counsel
II1. 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: OCT 2 0 1987 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: OCT 2.1 1987 BY: PHIL BATCHELOR by �✓ Deputy Clerk
CC: County Counsel County Administrator
CLAIM TO: bUAKu Ut ��rzi.�........, ..
Instructions to Claimant Return original application to
~ - Clerk of the Board
651 Pine St.. Room 106
Martinez, CA 94553
A. _ Claims relating to causes of action for death or-for Injury to
person or to personal property or growing crops must be presented
not later than the 100th day after the accrual of the cause of
action. ' Claims relating to any other cause of action must be
presented not later than one year after the accrual of the -cause
of action. (Sec. 911.2, Govt. Code)
B. Claims must be filed with the Clerk of the Board of Supervisors
at its office in Room 106, County Administration Building, 651 Pine
Street, Kartinez, California 94553.
C. If claim is against a district governed by the Board of Supervisors,
rather than the County, the name of the District should be filled in.
D. If the claim is against more than one public entity, separate claims
must be filed against each public entity. .
E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at and
of tKis form.
RE: Claim by )Reserved for Clerk's filing stamps
JOHN V. LELAND
Against the COUNTY OF CONTRA COSTA)
or DISTRICT) ` oo
(Fill n nameT ;
The undersigned claimant hereby makes claim against the County of Contra
Costa or the above-named District in the sum of $ 1,115.00
and in support of this claim represents as follows:
I:" lien a�a the aamage or in�uzy occur? ZGive exact date and �iourT
Between 08 June and 13 June, 1987; my DATE OF DISCOVERY: 13 June 1987.
�— —��� -------- ------------ — ----..sem—��—i �— ���—
�lfiere aid-t�ie'aamage or �n3ury occur? Zlnclude city and countyf
At 151 Flora Avenue , Walnut Creek, California 91 595
County of Contra Costa
Now aid the damage or �n3uty occur? ZGive" uII deta�Ss, use extra
sheets if required)
See attached statement .
at p`si`ticu3a"r"act oi'oani"ss�on'on the"pait o "county"oi'distr�et
officers, servants or employees caused the injury or damage?
Omission of proper notice . See attached statement.
(over)
5. Uilhat are the names of county or district officers, servants or' '
employees causing the damage or injury?
Ken S chunk of the Community Development Dept (attention Clyde Beard)
6. i��iat-damage or Injuries clo you claim resulted ZGiveuII extent
of inj ies or damages claimed. Attach two estimates for auto
damage
See atter ched statement.
--------------------------------------------- -- ------------- ---- ---
7. How was the amount claimed above computed? iIncivde the estimated
amount of any prospective injury or damage. )
See attached statement.
----------------------------------------------- - -------------
-
�. Names and addresses of witnesses, doctors and hospitals.
The removal of the autos took place when I was out of town . _'Pee
attached statement . Oell% jAlc�; i �. �'x div !� p� tea,✓
«
19 UZ/Ar,4= /fig' _x- A-WJ Cv.:T�✓dAL� a;�'� i/�[- � �5)O� O
'' �9�I,c � U'J✓�iL.�, /rf:4i'�'i i T ��i /A�;, �/F'�iC.�I,n/� . /''J�.�[I O '�✓,���.L.
414,E t/�+y.�✓c: �4 � .�/��'.f,�= �.��d w'i�✓G- / O�,�iJ-�i� =�.Srr�G l�
t�ie�axpenditu�es. .you made .on account of is accident or In ury:/
DATE ITEM AMOUNT
}
i
Govt. Code Sec. 910.2 provides:
•The claim signed by the claimant
SEND NOTICES TO: (Attorney) or by some vemson on his behalf. "
Name and Address of Attorney YZ�_ OHN V. LELAi1D
C a ants Signature
P. 0. BOX 12002
Address
OAkd.AigD, CSL IFORY4IA 9h6OL
Telephone No. Telephone No. 536-3228
NOTICE
Section 72 of the Penal Code provides:
'Every person who, -with intent to defraud, presents for allowance or
for payment to any state board or officer, ' or to any county, town, city
district, ward or village board or officer, authorised to allow or pay
the same if genuine, any false or fraudulent claim, bill, account, voucher,
or writing, is guilty of a felony."
Ccs
CLAIM COVERS THE FOLLOWING LOSS S : /17
eS
f ,► v� I�- / y= �a D Q L� �. g / d S l �D A/,S l\
if',4;� G A/ !3-2
w 25. 0 Brand-new jack stand under left front *feel of
a 1963 Buick Special A`NP 758, at time of tow-away
20 .00 For four 30-1b sacks of "Johnny Cat" cat litter
taken from adjoining garage at time of tow-away
$250.00 for value of the Dual-Path transmission in the
1,063 Buick S;,ecial AWP 758
$350.00 for fully-operational drive line in said vehicle .
This is the 1986 price for these Darts ; they are
almost impossible to obtain in 1987, as there are
no 'subst1.tute harts available for the (a) center
carrier beQring , or (b) the constant-velocity
universal joint which isin the center of this
two-Dart drive line, however am informed that
the Drive Line Service of Concord can re-build this
constant-velocity portion, by itself, for $ 375.00
000.00 for value of the chrome on the 199 DeSoto Carry-all
Sedan . The Community Development Department,
651 Pine Street, Martinez; California , has the
license number on their record .
000.00 for the Powerglide Transmission in the 1962 Bel
Air light green four-door sedan . This transmission
was brand new except for just under 3,000 miles
wear on it since it was r_urchased as .,a rebuilt,
and these rebuilt6 run over $700 .00 today. As above ,
the license number is on record in the Community
Development Department office .
The above vehicles were allegedly "abated" and removad
from my property as an alleged public nuisance .
These vehicles were pulled away from my property at
151 Flora Avenue , Walnut Creek, California, 91595, in the
time period 08 June - 13 June, 1987, inclusive , and the said
Community Development Derartment refuses to name the emet
date for me . The basis for items 3, h, 5, and 6 of my claim
is that I was never given any prover notice by registered or
certified mail . I am entitled to items 1 and 2 of my claim
regardless . 9W��O
! �
CLAIM
BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA
Claim Against the County, or District governed by) BOARD ACTION
the Board of Supervisors, Routing En;;orsements, ) NOTICE TO CLAIMANT October 20, 1987
and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of
iifGrnia Government Codes. ) the action taken on your claim by the Board of Supervisors
(Paragraph IV below), given pursuant to Government Code
Amc•ur:t: $100 , 000 . 00 Section 913 and 915.4. Please note all
CLAIMANT: JACQUELINE TURNER SLP � � �Q
c/o Mackey, Rozanski & Friedland 87
ATTORNEY: 1754 Technology Drive #224 ,.,, .. _
San Jose, CA 95110 Date received
ADDRESS: BY DELIVERY TO CLERK ON September 22 ,
BY MAIL POSTMARKED: September 1 , 1987
1. FROM: Clerk of the Board of Supervisors TO: County Counsel
Attached is a copy of the above-noted claim.
IL BATCHELOR, Clerk
DATED: September 24, 1987 ��; Deputy
L. Hall
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: ' 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: OCT 2 O 1987 PHIL BATCHELOR, Clerk, By vt G[ 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: OCT 2 ' 1987 BY: PHIL BATCHELOR by Deputy Clerk
CC: County Counsel County Administrator
1 - -- CLAIM AGAINST PUBIC ENTITY
DNI ING MAINTOW'10E
2 [GOV. C. §§905, 905. 2, 910, 910. 2]
3 1. JACQUELINE TURNER hereby makes claim against the PUBLIC
4 WORKS DEPARTMENT OF CONTRA COSTA for the sum of an undetermined
5 amount at this time and makes the following statements in support
6 of the claim:
7 2 . Claimant's post office address is 2429 Aberdeen Way
8 #2 , Richmond, CA 94806.
9 3 . Notice concerning the claim should be sent to N,ACKEY,
10 ROZANSKI & FRIEDLAND, 1754 Technology Drive, Suite 224 , San Jose,
00 11 California, 95110;
Z2
J0
a N Q 112 4 . The date and place of the occurrence giving rise to
D
w0 w�o
wo _,1 13 this claim are 6/18/87 in the City of San Pablo, at the
L1--J U)<f
�SZN>ZN
—°j<¢og 14 intersection of San Pablo and Rivers.
Ya0LL0
Lnw�»7-
Z000uz 15 5. The circumstances giving rise to this claim are as
QaQowoWX
9 g
Ooa=°�
Wa WZw 16 follows: Claimant was stopped at a stoplight going west at the
A. WV U)
Yw r 17 intersection of San Pablo and Rivers. After the light turned
�a 18 green for Claimant, Claimant entered the intersection and was
a
19 struck on the right rear of her vehicle, which caused serious
20 injury to Claimant. The drive of the other vehicle claimed they
21 had the green light, thus giving rise to a question of whether
22 the signal light at that intersection was in proper working order
23 at the time of this accident.
24 6. Claimant's injuries are unknown at this time;
25 7. The names of the public employees causing the 41' !�
26 claimant's injuries are unknown at this time
27 RECEI ]ED
28 '
�-
1 8 . The claim as of the date of this claim is still of an
2 undetermined amount;
3 9. The basis of the above amount is as follows:
4 Medical Expenses Incurred to Date: $undetermined
Estimated Future Medical Expenses: $undetermined
5 Loss of Wages : $undetermined
General Damages : $100, 000. 00
6
TOTAL : $undetermined
7
9 Dated: September 14 , 1987
vI D" t� FARLING
10 MACKEY•, ROZANSKI & FRIEDLAND
Attorheys for Claimant
0z 11
Z2
Q¢
000 N 12
w¢ w�
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0a Z N>Z N
14
ZLLEr(94W
0000z 15
NaE�onX
Ooazow
16
�a 2zw
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Vz
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19
20
21
22
23
24
25
26
27
28
1 DECLARATION OF SERVICE BY MAIL
2
3 Case Name: JACQUELINE TURNER Case No. :
4
5 I declare that:
6 I am employed in the County of Santa Clara, California. I am
7 over the age of eighteen years and not a party to the within
8 entitled cause; my business address is: 1754 Technology Drive,
9 Suite 224 , San Jose, California 95110.
10 On SEPTEMBER 14 , 1987, I served the attached:
]0 11 CLAIM AGAINST PUBLIC ENTITY
7_
La
°C
no 12
N
UM wo
�Q Nawl,
Lon
13 in said cause, by placing a true copy thereof enclosed in a
�6ZNjZN
-°g
a: 14 sealed envelope with postage thereon fully prepaid, in the United
Z'u
7U-
CC0<w
11-o0oz 15 States mail at San Jose, California, addressed as follows:
JaLoul=
boa.=°w
16 SAN PABLO PUBLIC WORKS DEPT. PUBLIC WORKS DEPT.
� wz
CL U,
S1-a
#1 ALVARADO SQUARE OF CONTRA COSTA
�w 17 SAN PABLO, CA 94806 1619 SHELL AVENUE
_¢ MARTINEZ, CA 94553
a 18
_Q
19
I declare under penalty of perjury that the foregoing is true
20
and correct, and that this Declaration was executed at San Jose,
21
California on SEPTEMBER 14, 1987 .
22
23
24 L.
LORI J. RICH
25
26
27
28
CLAIM
BOARD OF SUPERVISORS. OF CONTRA COSTA COUNTY, CALIFORNIA
Claim Against the County, or District governed by) BOARD ACTION
the Loard of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT October 20 , 1987
and Board A;.tion. All Section references are to ) The copy of this document mailed to you is your notice of
Calif-.rria Government Codes. ) the action taken on your claim by the Board of Supervisors
(Paragraph IV below), given pursuant to Government Code
Amour.: $25 , 000- 00 - Section 913 and 915.4. Please note all "Warnings".
:`C)u G e 1
CLAIMANT: CURRY JACKSON
c/o Nanette Lavala SEP 2 03 1987
ATTORNEY: 3615 Bissell Avenue
Richnond, CA 94805 Date received :"
ADDRESS: BY DELIVERY TO CLERK ON September 2 i , 19$7
BY MAIL POSTMARKED: September 22 , 1987
I. FROM: Clerk of the Board of Supervisors TO: County Counsel
Attached is a copy of the above-noted claim. -
September 24 1987 HHIL BATCHELOR, Clerk
DATED: p er ' BppY: Deputy G
4
L. Hall
II. FROM: County Counsel TO: Clerk of the Board of Supervisors
VNThis 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: C 11i} 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 0 DER: By unanimous vote of the Superviscrs 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.
OCT 2 0 1987
Dated: 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 1 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.
OCT 21 1987
Dated: BY: PHIL BATCHELOR byY%IOCZ6�1 Deputy Clerk
CC: County Counsel County Administrator
651 Pine St., Im m Lww
Martinez, CA 94553
A. Claims relating to causes of action for death crfor injury to
person or to peraoVrMoey or growing crops must be presented
not later than theafter the accrual of the cause of
action. -. Claims reto any other cause of action must be
presented not later than one year after the accrual of the -cause
of action. (Sec. 911.2, Govt. Code)
S. Claims must be filed with the Clerk of the Board of Supervisors
at its office in Room 106, County Administration Building, 651 Pine
Street, Kartinez, California 94553.
C. If claim is against a district governed by the Board of Supervisors,
rather than the County, the name of the. Distriet should be filled in.
D. If the claim is against more than one public entity, separate 'elaims
must be filed against each public entity. .
E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at end
oft-His form.
RE: Claim b )Reserved for Clerk's filing .stamps
Ly"r_j Ti- ci rjt A
RECEIVED
Against the COUNTY OF CONTRA COSTA; _ >3 138r
.or DISTRI C:') o�
(Fill in name Dead])
- -The undersigned claimant hereby makes claim agains of. Contra
Costa or the above-named District in the sum of $
and in support of this claim represents as follows:
-- __--- -e------S. --- -------------xac ----- --- ----
mien did the damage qr �n�ury occur? ZGive et date ani �iourj
erg ,
cin a r�� 66JJ.;S •, a-� {�r x Of
/'� �1 � �i�1 is .'� �j..�, Y � t, ..3 �'`� f+. ��,'�(/!�,��i :�l; ' r•
v'��� 'I1�� � � i I'L.�+�J` !��t�J,� F f r fr �f�+ �l 1 �j {, '��G <(J7��•?.����+y%. •,r
— d- ------=— coEM
-- --- ---{-
lfiere i. t e amage or In3ury occu IMud; city and '
��( }1••, ..:.�� ,��.(,!.:^Ec� 4`�"' �� I�'�G�'-�'rh e$. i��.�E.�!�",Gj� �st} f�';�, 1."��+ r,i _�: �,°7 u,.
.0 -��. Cc .t r, 1 0 `� (�� per, 3 i
os
3. row did c
the damage or injury ocur, (Give 7-11—Mall-S-0-Use
_II Mails, use extra
sheets if required)
me s m e ues '
�c�b"�r hecske�J-f�, n�rsE ,�c -Ihe•� Q� ��c, 15�•���m�� esc�rcD FS
�,\It.brown P;I(s,17ask her uJh `�S S? sh s tkn�
s ,.���
a. khat particular act or omissiontet on the part of county or � str�ct
officers, serve s; or em s caus d the i 'ury or damage?
11+�� CYDne +1-th�S Sh�o✓�ul 'f" Met.
11 Wtti '�11 f J � �?� -� �. pr r 6 r_ 0 A 4-, �T of 19 u l)A v prv��, A/C .
L•� �j or
nt4 l . .` S� + r�/ 1 �! bu i4
• _�lV f
r yl�s o v e.rr.�os jlrrr+�ha� r, Ec.#,�� m Y hekrt-dea�l-a�cU s}�Ee�.l, ltd Fec f
�Op b to h,tn►"i F+~�e rPcJh:p�o �t- y e f,
51 WMAt are the names of count or' distt'fct o f'cera, ery is or
y ak
employees causing the daage r in jury? ^ � ✓+ ►��vrnc�.��
��' i C.�? f G►�'G �,' �E, rf' tPY,�� .0 i 7+e,tr GI.I 't S 0 ZT elv?-11t 1 .
c
1 � l n'0`_rI�h S
r r � 14� C��'�;.+�,,tA•r.F•rt1.. IC/t Gt� Y+� L� . t'ila.'S��i.�
6. What damage of+Injuries do yo claim re9u ted? G L u 1 extent . "
of injuries or damages claimed. Attach two estimates for auto
damage
Vs a, ('esu 14-tt�,'� C:_ I �ipw, e -�o� buvz r�
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7. How was the amount claimed above computed? (Include the est--Maied
amount of any prospective injury or damage. )
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rY`i6G1(% \'Mei?' €( �'rT �w /ri G!!o
o or 4 M2-y
rrr rrr rr _� i r'i. ` t-\ T r rr rrrr rrr rrrr
r
8. Names and addresses of witnesses, doctors and hos1pitals.
(0;,�'`r"�� c+^ ►� f, r `..�i.�..�v ►1f'AL ►.rl -'fie:. (Le-6/&6k 44C
�.,
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�S. List the expenditures you made on account of anis accident oz injury:
DATE. ..�.... .....�...,.�•„,,._ ITEM AMOUNT
t
Govt. Code Sec. 910.2 provides:
"The claim signed by the claimant
SEND NOTICES TO: (Attorney) or by some person on his behalf. "
Name and Address of
Attorney
,Ciffgnafdtls, i nature '.
I� k31C(�� �j Addresses
Telephone No. — j 7 Telephone No.
NaTICE
Section 72 of the Penal Code provides:
"Every person who, with intent to defraud, presents for allowance or
forpayment to any .state board or officer, ' or to any county, town., City .
district. ward or village boaicd or officer, authorized to allow ,or pay
the same if genuine, any false or fraudulent claim, bill, account, voucher ,
or writing, is guilty of a felony. "
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