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HomeMy WebLinkAboutMINUTES - 10081991 - 1.17 1,17 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 October 8, 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: $1920.00 Section'913 and 915..4. Please note all "Warnings". CLAIMANT: PAUL S. MARTHALER P.O. BOX 596 ATTORNEY: EL CERRITO CA 94530 SEP 13 1� 1 Date received ADDRESS: BY DELIVERY TO CLERK ON September 11, C09% COUNSEL BY MAIL POSTMARKED: Via Risk Management I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. BATCHELOR,DATED: September 13, 1991 JVILATCHELOR, Clerk ; Deputy �! I FROM: .County Counsel TO: Clerk of the Board of Supervisors This claim complies substantially with Sections 910 and 910.2. ( ) This claim MILS 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: 1113 13 91 __ 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 (-1/) 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 0 8 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 co 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 claimantas shown above. 0 Dated: �l�l d t2 1591 BY: PHIL BATCHELOR by O Deputy Clerk CC: County Counsel, County Administrator 0 :1 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..l00th 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-pr,.-. crops and which•accrue on or after January 1, 1988, must be presented I 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 of2the 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 RECEIVE Against-the County of ContraCosta ) or ) ~: CLERK BOARD OF SU District) PERV _ . .) ... CONTRA COSTA CO. Fill in name The undersigned-claimant hereby..makes claim against the County of Contra Costa or the above-named District in the sum of $ / Q,y a and in support of this claim represents as follows: N--N---_N---_N--N --N--_ _---_--N-_--N--_N_-N_-N-N_--__-N--- 1. 1When did the damage or injury occur? (Give exact date and hour) ------------------------------------------------------------------------------------ 2.: Where did the, damage .or- injury occur? (Include city'and county) -------------------N-------__--NN-N---_-NN_----_N_N---N--_-N------N------ 3• How did the damage or injury -occur? (Give full.details; use extra paper if required) -------- ----- --------- -------------------- -N-----N-----_-- 4. .What particular act or. omissionion the part of county or district officers, servants,.or ,employees caused the injury or damage C11 XL�l (over) 5. 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. ----- - ----------------- ----------------------------------------------------------- 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) t -------------------------------------------------------------- -------------------- $. Names-and addresses of witnesses, doctors and hospitals. ------ ------ ---------—-----------— ——----------- ----------------- - 9. ------ ------------------ -------------------------------- 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) b some Person, on his behalf." Name and Address of Attorney Claimant's Signature - Address Telephone No. Telephone No. NOTICE Section 72 of the Penal Code provides: .'-. "Every rovides '- "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. Visible Damage Quufl4115 81 x NAME�- —� vt�T �P� YEAH MAKE ' Ild .,.,_—MODELRr_L2 ADDRESS Ld^y� � � �2�--. LICENSE NO. ! �,f `i(�V 1 ,MILEAGE C1TY_..� _I .._STATE--ZIP _. VIN NO. ._['1 .. H.PHONE- W.PHONE _ PROD.DATE L BODY CODE —PAINT TRIM INS.CO. --ADDRESS-------DATE OF LOSS CLAIM NO. ADJUSTER.. PHONE ___ — —LIC.NO. FILE NO. p-p. LINE RE- RE- DETAILS OP'ftEPAIR PARTS INDEX LABOR HOURS NO. PAIR PLACE R=Repair S<Stra{ghten A=Aftermarket N=New. PI PARTS SUBLET/MISC. =Racycle/Rechrome/Recore U=Used R=Rebuilt BODY PAINT FRAMEMECH -1 _ If t (D - 2 F 3 s e - .41 Ao 12 13 --- 14 - 1 15 _ 1 r 18- � t' 1 g _. 20 21 _—f .._ - ---- --- ----- -- 22 _— -- ----- — _ 20 4 24 25 26 y 27 OLD PARTS WILL BE DISCARDED UNLESS OTHERWISE INSTRUCTED TOTALS SON: S AFTER THE WORK HAS BEEN STARTED,ADDITIONALLY DAMAGED OR WORN PARTS ARE DISCOVERED WHIC::o.eRE NOT EVIDENT ON FIRST INSPECTION.THIS DAMAGE REPORT DOES NOT COVER OR INCLUDE ANY ADDI- L� BODY hrs, �� TiONAL PARTS OR LABOR WHICH MAYBE REQUIRED.ALL PARTS,PRICESARE SUBJECT?'O INVOICE. A FAFAINTI.Q j�—_hrs. - 1 hereby authorize the above work and acknowledge receipt of copy. —_ "� FRAME___—hrs.@ Signed X__ ------ -- _ _ Date-- -- R —, MECH__ hrs.@ — PARTS Prices subject to invoice SUBf_ETIMISC L NEOUS__ -- Paint SJpplilrs.@ _., Body Supplies_____hrs.@_ — 4960 PaC#t000 SW� Towing/Storage -_- Mwjinez, Caf0 EPA/Waste Disposal Charge-- Phone harge _Phoma (416) 372-SM BODY�pss�lW�ApOy� S SUB TOTAL .............. ,w `sillVfd '� i P" V - TAX. --V-on WRITTEN BY TOTALS 1eq 4-�A ©1968 I1D/E/A inc.Form No,1024 VD/E/A inc.,One I/D/EIA Way,Caldwell,10 83605-6902•CALL TOLL FREE 1-60D-635-9261 -------------------------------------------- ---------------------------------------------------