Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
MINUTES - 11302004 - C38
CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOMW ACTION.-NOVEMBER 30) 2004 Claim Against the County, or District Governed by ) the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT sand Board Action. All Section references are to ) The copy of this document mailed to you is your California Government Codes. ) notice of the action taken on your claim by the Board of Supervisors. (Paragraph IV below), given Pursuant to Government Code Section 913 and s F 3 915.4. Please note all"Warnings". AMOUNT. $3,000,000.00 CLAIMANT: DENISE SCMIDT fir ATTORNEY: PAUL N. HALVONIK DATE RECEIVED: OCTOBER 19, 2004 ADDRESS: 2600 TENTH STREET, BY DELIVERY TO CLERK'.ON: OCTOBER 19, 2004 BERKEI ', CA 94710 HAND - BY MAIL POSTMARKED: DELIVERED FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN SWE E rk OBER 19 2004 Dated: � By: Deputy II. F3.2OM: County Counsel, TO: Clerk of the Board of Sup icor (�'fihis 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 9113.8). ( ) 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 Counse 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. OAR) 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: A�GG t+ �✓ JOHN SWEETEN, CLEF.,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 deposite 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. *For Additional Warning See Reverse Side of This Notice. 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 fulls prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated `' JOHN SWEETEN, CLERK By Deputy Cler1 OFFICE OF THE COUNTY COUNSEL s � SILVANO B.MARCHES! COUNTY OF CONTRA COSTA �;: -�Cel, COUNTY CouNsec Administration wilding ,• - �> SHARON L. ANDERSON 651 Pine Street, 91",Floor � 8>° —��\ sSTar�r N Cw�EAssisr Martinez, California 94553-1229 8 5 GREGORY C.HARVEY (925) 335-1800 VALERIE J. RANCHE (925) 646-1076 (fax) 6 ' „ AssisTANTs 4 coo October 20, 2004 Paul N. Halvonik, Esq. 2600 Tenth Street Berkeley, CA 94710 Re: Government Tort Claim of Denise Schmidt Dear Mr. Halvonik: We are in receipt of your government tort claim, which is currently being;processed. If your intent was to file a claim against the Superior Court of California or one of its employees, please be aware that the Contra Costa County Clerk of the Board is not the proper entity to serve. Any claims against the court or its employees should be directed to the Superior Court Executive Office. Please see Government Code Section 915, subdivision(c) for further directions. Thank you for your attention to this matter. Very truly yours, SILVANO B. MARCHESI COUNTY" COUNSEL By: onika L. Cooper Deputy County Counsel MLC/kmo 10/14/2004 13;43 CONTRA COSTA CMJNTY CLERK OF Tl E 99333821 Np.041 901 R()ARD OF SUflE VISORS OF CONTRA COSTA COUNTY A. A claim relating to a cause of action for death or for injury to person or to personal property or growing crops shall be presented not later than silt months after the accrual of the cause of action, A claim relating to any other cause of action shall be presented not lager than one year after the accrual of the cause of action. (Gov. Code§ 9111.) B. Claims must be f:ledd with the Clerk of the Board of Supervisors at its office in Froom 106, County Administration Building,651 Pine Street,Martinez,CA 94553. C. if claim is against a district governed by the Board of Supervisors, rather dzan 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. ?Z at the end o4'this form. 060#1Wsrsrssssit*sssysssssssrssMe■was stssssssssMssrstoo sw■ws■.srrstrssstsss«r••s: M. Claim By. Reserved for Clerk's filing stamp t1-5 u �Jt ° ) EE ` Against fire County of Contra Costa or OCT 19 2004 District) ItERK BOAR �} {Fill in the name) �A��sx The undersigned claimant hereby snakes claim against the County of Centra Costa or the above-named district in the sura of S .000,606 and in support of this Maim represents as follows: I. When did the damage or injury occur? (Give exact date and hour) 2. Wixcre did the damage or injury occur? (Include city and county) 3. How did the damage or injury occur? (Give full details;use extra paper if required) J oe a- 4 What particular act or omission on the part of county or district officers, servants,or employees caused the injury or damage? c What are the yes of county or district off`iaers,servants,or employees causing the damage or injury? 1W,14/2004 13.43 CDNTRA COSTA COLNT`f CLERK OF THE 4 99333F"t.21 tO.041 902 6. What damage or injuries do your claarti resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage.) 7. How was the arnount claimed alcove computed? (Inelude the estimated amount of any prospective injurer or damage.) 8. Names and addresses of witnesses,doctors,and.hospitals: 9. List the expenditures you made on account of this accident or injury. sarrassssysatasrrssrrvsvasstra+tvsrvr:rvs+rsyssrssss�t�rrssssartavrssvrssvasvtaasevsar:vase ) Gov.Cade See. 914.2 provides"ne claim shall be )signed by the clamant or by some person on his behalf," U 12 NI l S TQ (AWmev� 1 Name and address of Attorney ) ts (Claimant's Signature) q q ) (Address) C Telephone N ' Telephone No. ••sarrssrasasssasasasssssarssasassaassrsssaYsasrasassssssssassrsssaswsrarrrra:asasava PUBLIC RECORDS NOTICE: Please be advised that this claim form,or any claire.filed with the County under the Tort Claims Act, is subject to public disclosure under the California Public Records Act. (Gov. Code, 66 6500 et seq.) I`urthemore, any attachments,addesxdums,or supplements atudied to the claim.form, including medical records,are also subject to public disclosure. •wawwwwrwaarwwrrwwwwrawwwwrwwraww.rwrwwrw04000*too apairrriaaarifrfraraaralr•raraavaswl NOTICE: Section 7Z of the Ferrol 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 4f not more than one year, by a fire of not exceeding one thousand dollars ($1,000.00), 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),err by both such imprisonment arid fine. Board. of Supervisors of Contra Costa.County Claim form. 3. The damage occurred when I was terminated as a result of an ex post facto policy created and adopted by select members of the judiciary and subordinate judicial officers of the Superior Court of California, County of Contra Costa, and the Court Executive Office of the Superior Court of California, County of Contra Costa, in retaliation for the assertion of my federal and state rights. 4. 1 ran in an election against a sitting judge. Select members of the judiciary and subordinate judicial officers of the Superior Court of California in concert with the Contra Costa County Court Executive Office of the Superior Court and the Administration of Courts adopted an ex post facto policy that was interpreted to disqualify me from my employment position and prohibit my application process for permanent status. These acts that resulted in my termination were a direct result of my having run in the 2004 election, were in retaliation for my candidacy, and a preventative measure to ensure that i could not enter the next judicial election as an employee of the superior court. 5. Judge Laurel Brady, Judge Thomas Maddox, Judge Lois Haight, Judge Barry Baskin, Commissioner Stephen Houghton and Ken Torre. b. Three million dollars. 7. Damages were calculated in the amount of salary and benefits that would have been conferred in the absence of the illegal acts of the aforementioned agencies and employees. & Not applicable. 9. Not applicable. CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION: NOVEMBER 30. 2004, Claim Against the County, or District Governed by ) the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to ) The copy of this document mailed to you is your California Government Codes. ) notice of the action taken on your claim by the Board of Supervisors. (Paragraph IV below), given Pursuant to Government Code Section 913 and 915.4. Please note all"Warnings". AMOUNT. UNKNOWN f YMs CLAIMANT: BERNADLvE GRAY ATTORNEY: ARTHUR A. LEVY DATE RECEIVED: OCTOBER 21, 2004 ADDRESS: 6211 MONADNOCK WAY BY DELIVERY TO CLERK ON:OCTOBER 21, 2004 OAKIAIND, CA 94605 BY MAIL POSTMARKED: OCTOBER 20, 2004 FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN SW Clerk Dated: OCTOBER 21, 2004 By. Deputy IT F�2.OM: County Counsel, TO: Clerk of the Board of Su ervisors (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 ITL 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. POARD ORDER: By unanimous vote of the Supervisors present: M" 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;- JOHN SWEETEN, CLERK,By , Deputy Clerk WARNING(Gov. code section 9 3) 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. *For Additional Warning See Reverse Side of This Notice. 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: -vAA#y//t JOHN SWEETEN, CLERK.By Deputy Clerk s L.AIM _ AGA{NST THE Ct, TMTY OF CONTRA COST ,-._ Before completing this farm,please read the Instructions on.the back.You have only 6 months fro t ubmtt this form and supporting documentation to the Controller or the Clark of the Board of Sup-0rvisors. 1,Claimant's Name and Home Address (Please Print) 2.Send Official Notices an rrespo n X04 BERNADINE GRAY BERNADINE GRAY OC!` KBpA 6211 MONADNOCK WAY 6211 MONAD_NOCK-WAY a, City OAKLAND , CA Zip 94605 Cif OAKLAND CA Zip 94505 3.Date of Birth 4.Daytime Telephone 5.Sochi Seourity Number 6. Bate of Incident 7.Time of Incident 2/8/05 510/568--5527 551-17-3421.; 5/21/04 9:22 A.M. 8.Location of Incident or Accident 9.License Plate Number, Claimant Vehicle 2801 Robert Miller Drive, Richmond, CA 10.Basis of Claim (State in detail, the known facts and circumstances attending the Incident identifying persons and City departments and property involved,and the cause thereof.Use additional pages K necessary and attach photos H available. See Instructions.) While sittina on schoolyard bench, it broke causing Ms. Gray to:• fall. She injured her low back., neck, right arm and shoulder. She has not worked since 9/21/04. Name, I_ . D. Number and Department Type of City Vehicle Vehicle License Number and Vehicle Number 11.Description of the Claimants damage, injury,or loss 12. Value of Clalmant's Lass or Injury and method of computation (See Instructions) I T E M S Medical Care $ ? Wage Loss $ ? Gengral Damages -_ TOTAL AMOUNT Court Jurisdiction: Municipal C] Superior 0 13.Witnesses(if any) Name BUSS. Address Telephone 1700 So. El Camino 1, Jean Chong Jaian Xiao San Mateo, CA 650/372--0211 2. I understand that if my claire is successful, any monies owed me may be offset by any as Not Write In This Space monies I may owe the City and County of San Francisco,for such items as traffic tickets, S.F.General Hospital unpaid bills,welfare reimbursements or overpayments,ate. 14.Signature of Claimant or Representative 15.0ate of Clalm CRIMINAL PENALTY FOR PRESENTi"G A F'RAUEULENT CLAIM OR MAKING A FALSE STATEMENT IS IMPRISONMENT FOR NOT MORE THAN 5 YEARS OR FINE OF NOT MORE THAN$25,000.00,OR BOTH. LAW OFFICES OF ARTHUR .A. LEVY 465 CALIFORNIA STREET,SCUTE 400 SAN FRANCISCO,CA 94104 (415)788-5389 RECEIVED FAX(415)788-5390 OCT 2 1. ZG04 SATE: October 20, 2004 q -] I ,LERKBOARD0FS0���VWRS }, CONTRACOST. Go, TO: CLERK OF THE BOARD 651 Pine Street Martinez, CA 94553 RE: Bernadine Gray vs. County of Centra. Costa, et al. Case No. Unassigned Dear Sir or Madam: Enclosed Please find: X The following document for filing: CLAIM FORM X Please return to this office, file, endorsed copies in the envelope provided. Filing fee of $ is enclosed. Other: Thank you for your kind attention to this matter. Very truly yours, .. LAW OFFICES OF A R A. LEVY ARTHUR A. LEVY AAI/1s Enclosure {s} CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION:NOj'R4BER 30, 2404 Claim Against the County, or District Governed by ) the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to ) The copy of this document mailed to you is your California Government Codes. } notice of the action taken on your claim by the Board of Supervisors. (Paragraph IV below), given Pursuant to Government Code Section 913 and 915.4. Please note all "Warnings". AMOUNT: $2.37.00 CLAIMANT: IFIL REESE ATTORNEY: UNKNOWN DATE RECEIVED: OCTOBER 21, 2004 ADDRESS: 1355 MT. PISGAH # 15 BY DELIVERY TO CLERK ON:OCTOBER 21, 2004 WALNUT CREEK, CA 94596 BY MAIL POSTMARKED: OCTOBER 20, 2004 FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN SW Clerk OCTOBER 21 2004 Dated: 5 By: Deputy II. MOM: County Counsel. TO: Clerk of the ward of Su ervisc-rs (This claim complies substantially with Sections 910 and 910.2. t { ) 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. ARD GIRDER: By unanimous vote of the Supervisors present: { This Claire is rejected in full. { ) Other: II certify that this is a true and correct copy of the.Board's Order entered in its minutes for this date. DatedX#1', t4r-AA-X` 4,11A4 JOHN SWEETEN,CLERK, By , Deputy Clerk WARNING(Gov. code seotion 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. *For Additional Warning See Reverse Side of This Notice. 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. Datedy' JOHN SWEETEN, CLERK By Deputy Clerk BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT A. A claim relating to a cause of action for death or for injury to person or to personal property or growing craps shall be presented not later than six months after the accrual of the cause of action. A claim relating to any other cause of action shall be presented not later than one year after the accrual of the cause of action.. (Gov. 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 fine 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. B. Freud. See penalty for fraudulent claims, Penal Code Sec. 72 at the end of this form. Ross rwwwwwwwwwwrwwwwwwwwrrwrwww:wwwwwwwwrwwwww:wwwwwwwrrwwwrwwrrwwwwwwwrwwwwwaI RE: Claim By: Reserved for Clerk's filing stamp CEt OCT 2 12004 Against the County of Cont a Costa or } IMEERK80AIRD OF S,,,PE_R3V1S RS. District) A COSTA CIO. (Fill in the name) } } The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named district in the sum of0D and in support of this claim represents as follows: 1. When did the damage or injury occur? (Give exact date and hour) 2. Where did the damage or injury occur? (Include city and county) `Y 3 How did the damage or injury occur? (Give full details; use extra paper if required) \c! + ` 1i ' tt+C . *ti .Y Yom` r a ^« :t "+ + ., �tcicm, <..fi d`Jtt t 'p1it.. x�t �3�0a. 4. What particular act or omission on the part o county or district offices, servants, Semp �ees caused the injury or damage? or Asa_S. �w�'��,t�t:� �'y,<��� •r,'a�-�0^s� �.'�- �r'�F� �;"�t�a �€_s'�..s.-� ��� ,{� f cc�:v:%`� ..ti.' .. �'{,. a ..',x '�#`4•L °w «,�," is "q' -s.A' <'' ' �y x`<`Y:,-M., y .> 3 :.t;_s . .• `R.�yy�i•• Vy_ L.+.��4. .. .�"Sse1'.3� °��`"� ��"aY94 �+k.i"'t!:,'�, 5 Wha are the names of county or district officers, servants, or employees causing the damage or injury? w:n a V WX. FMIn 6%1 #"t'tC f� ..i.�. �.X..- callk my L y tw(.^€,. _�j s iIN - 11a . ri 04 j mane .4 f5 1 Awn •"t, q ...%'�� -y `�,.,s,,.i e:.*o.>�''.. yy 's'3'"° `�.:�Eu'f�:.,. k*�`..y�` c;k} t•��., z'°y` . 0 F q 4y '2 ;.mitis: ,. ✓..'`: z. '> . a a •,�- .sr^s? p"\f ti ✓ a t. F t 6. What damage or injuries do your claim resulted? (Give full-extent of injuries or damages claimed. Attach two estimates for auto damage.) Cw.l-n ;�'e . " �i. 6 �l Ye�.`+,,'.. r `! G"�i.Y t� °P�Y`{.k:....... { 1' ... °S n e..2"'ve».. pcsVA.'lk\' 7. l:-Iow was the amount claimed above computed? (Include the estimated amount of any eA' prospective injury or damage.) INA14 8. Karnes and addresses of witnesses,doctors,and hospitals: iz , V-VL C,<_ 9. List the expenditures you made on account of this accident ori jury: f DATE TIME AMOUNT . ,c ■rsrrrrsrrrssrrwsrrswrrrrrrrrrrrrrrsrrrrsrssrrrswrrssrrsrssrsrrrssrrswersswrr•rrrrr■t Gov. Code Sec. 910.2 provides"The claim shall be signed by the claimant or by some person on his behalf:" SEND NOTICES TO: (Attorney) � Name and address of Attorney ) l } (Claimant's Signature) (Address) ) J1C re _ Telephone No. )Telephone No. cl asrwrrrsrrrrrrrsone*woos*swrsrarsrrwrrrrrsrswon rrrwrrrsssrwrrrsrrrrttrwrrrsswwrrssrwet PUBLIC RECORDS NOTICE: Please be advised that this claim form, or any claim filed with the County under the Tort Claims Act, is subject to public disclosure under the California Public Records Act. (Gov. Code, S§ 6500 et seq.) Furthermore, any attachments,addendums, or supplements attached to the claim form, including medical records,are also subject to public disclosure. ssrrrwarrrrawrrrrrss*sun man*rsrrrrssrrrrrrrrrrsssswrrrrrrrswrrrrrsrrssrrsrrrrrrsrrsst 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 dollars ($1,4010.00), or by both such imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ($10,000), or by both such imprisonment and fine. CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY i v/ BOARD ACTION: NOVEMBER 30, 2004 Claim.Against the County, or District Governed by ) the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to ) The copy of this document mailed to you is your California Government Codes. ) notice of the action taken on your claim by the Board of Supervisors. (Paragraph IV below) given jz f Pursuant to Government Code Section 913 and 915.4. Please note all "Warnings" AMOUNT: $500,000.00 � \ CLAIMANT: IRITA HENDERSON ATTORNEY: MARK V. MURPHY DATE RECEIVED: OCTOBFR 26, 2004 ADDRESS: LAW OFFICES OF MARK V. MURPHY BY DELIVERY TO CLERK ON: OCTOBER 26, 2004 18 ,CROW CANYON COURT, SUITE 380 SAN RAMON, CA 94583 BY MAIL POSTMARKED: OCTOBER 25 2004 FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. OCTOBER 26 2004 JOHN SW T lerk Dated: By: Deputy IT FROM: County Counsel. TO: Clerk of the Board of Supervisors (%.Ythis claim complies substantially with Sections 910 and 914.2. ( ) 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:` v .fi 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. ARD 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:, +1 & JOHN SWEETEN, CLERK, By , ]Deputy Clerk WARNING(Gov. code sec vn 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. *For Additional Warning See Reverse Side of This Notice. AFFIDAVIT OF MAILING I declare under penalty ofpedury 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- Or a� JOHN SWEETEN, CLERK By Deputy Clerk 09/09/2004 12,21 CONTRA COSTR COUNTY CLEW, OF THE a 9831E-493 N0.8S9 001 claim to: BOARD OF SUVERVISORS Or{CONTRA COSTA COUNTY a '1"1CNS iCL . A. Claims relating to causes cif action for death or for-inptry to person or to personal property or growing crops and which accrue on or beroTe December 31, 1981,must be presented not later than,the 10&day after the accrual of the cause ofaction.Maims ralatin,sg to gwses.ofwibn for death or for injury tet' person or to personal property or growing crops and which accrue on of after January 1, 1998,trust be presented not later than six mouths after the etc ,,J of the cause of action. Claims relating to any other cause 6factlon must be presented not later than me year alter the aomal of the cause,of acuate. (Govt Code 911.2.) ,. B. Claims must be filed with the Clerk of tete Board ofSupervisors at its offtct in Room 106,County Administration Building,651 Pine Street,Martinez,CA 94553. C. Yclaim is,against a district governed by the Board, df Stiperviters,ratter than the Couriy,the name of the District should be filled in. D . If the claim is against more than one public entity, s°parate claims mast be filed against each public entity. E. E[.AyA. See penalty for fravduleht claims,Penal Code Sec. 72 at the end of this farm. ####iW4il+Yki+iir#►'#i#yid#tt#M#kw�'W+�swbw+1#+d#+1#tIF##'bi�3*#iri#Itt#diitti##kith+d'*d+ls#kt'#ik+ii#1+M##y . RE. Claim By deserved for Clerk's filing stamp Irita Henderson TRECE� IVED Against the County of Contra Costa or ) 2 6 2004 C€.ERK ROaRD pc SUPERVIS( District) CONTRAC(7sT�:Cd. {Fill in name} ) The undersigned claimant hereby makes claim against the County of Contra Costs or the about-named district in the stern of S .5 o 0, 0 0 0 and in support of this claim rt7ments as follows: I. When did the damage or injury occur?(Give exact date-nrd hour) 6/l/04 2. Where did the damage or Tjury occur'(include city ar>d county) 780 21st Street at Carvin, Richmond., CA 3. Hover did the damage or injury oewo(Give Rall details;use extra paptr if required) The dangerous and defective condition of the sidewalk at this location caused claimant to trip and fall. P9/09/2e04 12:21 C`WPW C'o9TP COUNTY CLEW OF THE 90318483 ho.C88 002 4. *hit particular act or ornass'son on the pIn Of WUItty ter district offers, setvan% of employees caustd tht injury or damage? A failure to maintain the sidewalk in this location in a safe condition. S. What are the names orcounty or district officers, servants, or employees causing the damage or injury? The names of the responsible officers, servants and employees are unknown to claimant at this time. d. 'What damage or Nuries do you claim resulted?(Give fin`s extent of injuries or damages claimed,Attach two estimates for scute damage.) 1. Chest wall pain 2. Right wrist pain with swelling and snuff box tenderness 3. Bilateral knee pain 4 . Multiple contusions 5. Left wrist sprain 6. Neurological deficits in hand, wrist and arm 7. flow was the amount Maimed above computed?(Inclodc the estimated amount of any prospective injury of damage.) 'The amount is an estimate for claimants medical costs, pain and suffering and permanent residual impairment, ' 8. Names and addresses of witnesses, doctors, and hospitals. Claimant has treated through the Kaiser system in Richmond, Hayward and San Francisco facilities. 9. List the,expenditures you made on account of this acci6rt or injury. DAM TOE Claimant estimates she has $5,000 - $10, 000 in medical expenses to date. r.s.**«err+�+►rr�rr�+r«.�«rr+is«*.r«sir«aw��r*r.+►*s��•rt�ra��,rt�r��*t�tFt+►�s*t+�*�Mtv«r*«:st+r�rr+�s+r+r��r+►+�w* } Gov. Code Sec.910.2 provides"Tht claim must be signed by the claimant or by some person on his behalf." N933CFS T(?i At-tornev Name and Address of'Attomey } } Mark V. Murphy _, 18 Crow Canyon Court } (CUMZKVs Signature} Suite 380 San Ramon, CA 94583 } (Address) } Telepho"hlo. 925-552-9900 l Telephone NO. *�;t4�ty+rww��+l�kw�r�r�r�#��►�a�rs��r+►#�y�ri��i�a�rr�lrrri+te��vt+xti+as.►rYi�+kts�r+r�itr►�1�1tt*+s r��rs�r��,�rrs� NOTICE Secd06 72 of fhe PoW Coda prvs idas. VVeq peon*bo,with intent to defra 4.Praerb for dow ucx ar flat POMCM to SAY$tate board or officar,or to any msty,city,or distrust bomd or of m,,tuororized to 4owr or fay tees v=ii' nulee,any faleo or freudult*t bili,teaao=u vaucAer,or writing,it pterti"e either by imprisottmetst to ttu county X!for a perftatt of feet amen aeon one year.by a fine of not V004 am ted(flax 01 or by both web I>:tprio meat ad flee,ar by imosoeunrtt in*e ectad p iwk by#8ne of rent txnndietg tell tbtstuantd Ulm jilslAW),or by botb Nth impeisomnent and An. Law Offices of MARIA. V. MURPHY Centerpvint Building • 18 Crow Canyon Court, Suite 380 • San Ramon, CA 94583 (925) 552-9900 - FAX (925) 831-8483 Email mark mrninjurylaw.com R RECEIVED October 25, 2004 OCT 2 6 2004 t CLERK BOARD OF%iPERVI CONTRA COS ifi, VIA CERTIFIED MAIL/RET RN RECEIPT Clerk of the Board of Supervisors Room 195 County Administration Bldg. 551 Pine Street Martinez, CA 94553 Re: Cly Client: IRITA HENDERSON Gate of Loss: 611/04 Dear Sir/Madam: Please find enclosed a CLAIM AGAINST CONTRA COSTA COUNTY fora for the above referenced client. Very truly yours, A..X, Yt MARK V. MURPHY MVMfbkk Enclosure (as stated) CAdatMlIendees n,IritatttrCountyof CC.wpd REPLY TO SAN RAMON OFFICE ANTIOC€I OFFICE LIV FRMORE OFFICE PLEASANT HILL OFFICE 511,W.Third Street 197 South S Street 10 1 Gregory Lane 1152 Antioch CA Limrnore CA Pleasant Hill CA L C AIM �. BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION;-NOVEMER .30,2004 Claim Against the County, or District Governed by ) the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to } The copy of this document mailed to you is your California Government Codes. } notice of the action taken on your claim by the Board of Supervisors. (Paragraph IV below), given Pursuant to Government Code Section 913 and 915.4. Please note all"Warnings". :t AMOUNT: $360.00 CLAIMANT: tr �' RALPH CARI3ONE ..... ATTORNEY: UNKNOWN DATE RECEIVED: OCTOBER 27, 2004 ADDRESS: 5370 WILLOW LAKE COURT BY DELIVERY TO CLERK.ON: OCTOBER 27,__2004 DISCOVERY BAY, CA 94514 BY MAIL POSTMARKED: HAND DELIVERED FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claire. JOHN S WEB, ' lark Dated: OCTOBER 27, 2004 By: Deputy H. Fr OM: County Counsel. TO: Clerk of the Board of Su rvisors (�)4his claim complies substantially with Sections 910 and 910.2. 1 ( } This Claim FAILS to comply substantially with Sections 910 and 914.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( } Claim is not timely fled. 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; r° ° 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. OARD ORDER: By unanimous vote of the Supervisors present: ( This Claim is rejected in Bull. ( } Other: r I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated:��e X'' d JOHN SWEETEN, CLERK., By ,Deputy Clerk WARNING(Gov. cede se ion 913) Subject to certain exceptions,you have only six(5)months from the date this notice was personally served or depositec in the mail to file a court action on this claim. See Government Code Section 945.5. 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. *.For Additional Warning See Reverse Side of This Notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that I a.m.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: eAVrA&.*1-V� JOHN SWEETEN,CLERK.By Deputy Clerk BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT A. A claim relating to a cause of action for death or for injury to person or to personal property or growing crops shall be presented not later than six months after the accrual of the cause of action. A claim relating to any other cause of action shall be presented not later than one year after the accrual of the cause of action. (Gov. 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. !R#as R Ross RMR!!R R R!R R R!as R 111101114111!!####!R i!!!!#!!!*i!R#!!!R R!!!!R!!!!i#!!sons*!C RE: Claim.By: Reserved for Clerk's filing stamp RECEIVED Against the County of Contra Costa or ) OCT 2 7 2004 District) Fill in the name ) CL Bt�ARD OF SUPER SORB: CONTRA="TSTA CO. The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named district in the sun of$ ' and in support of this claim represents as follows: 1. When did the damage or injury occur? (Give exact date and hour) 2. Where did the damage or injury occur? (Include city and county) V' '.sno u f cowrV.,4 ccsm Cea.Ify 'AlAY119OX.; c Z i3 t : 9b, 3. How did the damage or injury occur? (Give.full details; use extra paper if required) W X J/-,101 V, ,t IA,- -µ0w7111 1,,V .-Aiy IX u c k. 1?pf o ecus°,r "cr1eK1 > i c R wjrs- ?'tq,'Vedr''W& lu iJ,r t t , r we plo:s eh, 'r -rf W/Oovp h'OW o .SPAAY e't Aal""lea r" ra/n 1'^I� 0/vt va e r c L d ;,exrAX*4}� c re'd`o,# ,P� c 4. What particular act or omissi8n on A e part of county or df strict officers, servants, or employees caused the injury or damage?fit��? (o�r.s",�`gu e)~rco, i-p,ucA ' ,�l�J /V 213 y rguc 1114 Vff , 'fin i eje ? X�D S.e oy, 5 What are the names of county or district officers, servants, or employees causing the damage or injury? g 6. what damage or injuries do your claim resulted? Give full extent of injuries or damages claimed. Attach two estimates for auto damage.) p S-,o�q,6y cw,rZ My V,�.14/c 4 7. How was the amount claimed above computed: (Include the estimated amount of any prospective injury or damage.) l t,+jr', ' r�r 15 0 viler"r"5*6114x- a-r 8. Names and addresses of witnesses, doctors, and.hospitals: 9. List the expenditures you made on account of this accident or injury: DATE TIME AMOUNT ■rrrrrrrrrrwrrrrNoon rrrrrrrrrrrrrrrrr rrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrragog rmanna roI ) .Gov. Code Sec. 910.2 provides"The claim shall be ) signed by the claimant or by some person on his behalf." SEND NOTICE TO: _(Attorney) } Name and address of Attorney ) ) (Claimant's Signature) ce °Z (Address) ) Telephone No. ) Telephone No. 4 13 " 72 3 o ■:rrrrrrrrrrrrrrrrrr*mass rrrrrrrrrrrrrr■rrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrago Kokomo PUBLIC RECORDS NOTICE: Please be advised that this claim form, or any claim filed with the County under the Tort Claims Act, is subject to public disclosure under the California Public Records Act. (Gov. Code, §§ 6500 et seq.) Furthermore, any attachments,addendums,or supplements attached to the claim form, including medical records, are also subject to public disclosure. rrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrHanson rrrrrrrrrrrrerrrrrrrrrrrrrrrrrrrrrrrrrk 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 dollars ($1,000.00), 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. ALL PRO DETAIL SHOP Invoice 2995 NORTH NAGLEE ROAD TRACY, CA, 95304 1 Date Invoice# Pill To 0 lee 1'f�c' v Fs E s �js1 tf �%3-6;'cfY P.O. No. Terms Project Quantity Description Rate Amount f y�; i 4 I 1 { 1 ' e INVOICE CA%71 � AUTOMOTIVE PAINT REPAIR 2022 Latour Drive • Livermore, CA 94550 (925) 292-8985 (510) 507-2291 DATE , CUSTONffiR: 1" a'i � iii)Rv_ APPROVE BY DEPT.[]NEW []USED []SERVICE YOUR MR TECHt3 MT CLAIM BOAR,A OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION: NOVEMBER .30, 2004' Claim Against the County, or District Governed by ) the Board of Supervisors,Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to } The copy of this document mailed to you is your California Government Codes. ) notice of the action taken on your claim by the Board of Supervisors. (Paragraph IV below), given Pursuant to Government Code Section 913 and 915.4. Please note all"Warnings". AMOUNT: $25,000-00 CLAIMANT: DANNY EUGENE LE BLUE ATTORNEY, UNKNOWN DATE RECEIVED: OCTOBER 28, 2004 ADDRESS: 214 ORANGEVALE, BY DELIVERY TO CLERK ON:OCTOBER 28, 2004 PITTSBURG, CA 94565 BY MAIL POSTMARKED: HAND DELIVERED FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. OCTOBER 28' 2004 JOHN SINE&T Jerk Dated: By: Deputy — IT WOM County Counsel TO: Clerk of the Berard of' a isors ( his 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: ZL ? 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. Dated. ° . JOHN SWEETEN,CLERK, By , Deputy Clerk WARNING(Gov. code secti n 913) Subject to certain exceptions, you have only six(6)months from the date this notice was personally served or deposited in the snail 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. *For Additional Warning See Reverse Side of This Notice. 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 AO OIN SWEETEN, CLERK By Deputy Clerk BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIM-ANT A. A claim relating to a cause of action for death or for injury to person or to personal property or growing crops shall be presented not later than six months after the accrual of the cause of action. A claim relating to any other cause of action shall be presented na later than one year after the accrual of the cause of action. (Gov. Code § 911.2.) B. Maims 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 claire 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. B. Fraud. See penalty for fraudulent claims,Penal Cade Sec. 72 at the end of this form. avow f•Rili#Ii■s; us*auxng:MflfltlFsagoa it rikillfY•i•014tll111011/111/■at RE: Claim By: Reserved for Clerk's filing stamp hECEIVED Against the County of Contra Costa or ) OCT 8 2 CLERK BOARD OF SUPERVISORS .District) ,CONTRA COSTA CO. (Fill in the name) ) �� 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: 1. When did the damage or injury occur? (Give exact date and hour) 2. Where did the damage or injury occur? (Include cityand county) 3. How did the damage or injury occur?(Give full details; use extra paper if required) � ' 0... a i� 4. What particular act or omission on the part of county or district officers, servants, or employees caused the injury or damage? 5 What are the names of'county or district officers, servants, or employees.causing the damage or injury` ,r ¢' �' Vve t f } 6. What damage or injuries do your claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage.) ?t ry 7. How was the amount claimed above compu ? (Include the estimated amount, of any prospective injury or damage.) x r $. Names and addresses of witnesses,doctors and ' _. s""t"t..: i3-"' 'E...}s.F '�.,.. t -'�•�.., c....2W.�.:.,C'fr' i #. car < .k .�,G+ 9. List the expenditures you made on account of this accident or injury: TIME .DATE AMOUNT t� err a r coma arass■a on It an r a s amass a a resume Is a a a a won*a r s■a r as amass u r a m s r e r an as r a UK as amass a a i } Gov. Code Sec. 910.2 provides"The claim shall be signed by the claimant or by some person on his }behalf." SEND NOTICES TO: (Attorney3 1 Name and address of Attorney ) ✓ �+ } � laimartt's Signature) / f e � .. ,.. .. } J (Address) �S Telephone No. }Telephone No. "` x._.. ors■aararera:erreraasassarUwe rrrmrmrraaerrmrarm*amrrmwas rrerrrleererrreweaasamreramrrl PUBLIC RECORDS NOTICE: Please be advised that this claim form, or any claim filed with the County under the Tort Claims Act, is subject to public disclosure under the California Public Records Act. (Gov. Code, §§ 6500 et seq.) Furthermore, any attachments, addendums, or supplements attached to the claim form, including medical records,are also subject to public disclosure, rrrrarrrrraereararrmarrrrremrrerrrerrrrrememrrmrmrerrrerraeaarrrmrrarrraerrarrrarrrrx NOTICE: Section 72 of the Penal Code provides: Every person who, with intent to defraud, presents for allowance or for payment to any state beard or.officer, or to any county, city, or district beard 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 dollars ($1,000.00), or by both such imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ($10,000),or by both such imprisonment and fine. CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BQARD ACTION:NOVEMBER 30, 2004 Claim Against the County, or District Governed by ) the Board of Supervisors,Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to } The copy of this document mailed to you is your California Government Codes. ) notice of the action taken on your claim by the Board of Supervisors. (Paragraph IV below), given ,,. Pursuant to Government Code Section 913 and 915.4. Please note all "Warnings". AMOUNT: $2,716.54 CLAIMANT: JASON PERRY ATTORNEY: UNKNOWN DATE RECEIVED: OCTOBER 29, 2044 ADDRESS: 4911 FRAY AVENUE BY DELIVERY TO CLERK ON: OCTOBER 29, 2004 RICHMOND, CA 94804 BY MAIL POSTMARKED: OCTOBER 28, 2004 FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN SWE E erk Dated: OCTOBER 29, 2004 By: Deputy II. MOM: County Counsel: TO:Clerk of the Board of Supe isors �,lihis 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: ¢ .;'. `` ,p" By; 'M�f ' �' ', . 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. EJOARD ORDER: By unanimous vote of the Supervisors present: (vK 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. Datedvg�J4w� $ JOHN SWEETEN, CLERK,By , Deputy Clerk WARNING(Gov. code sect' n 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. *For Additional Warning See Reverse Side of This Notice. 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: �`r,d" JOHN SWEETEN, CLERK.By Deputy Clerk BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT A. A claim relating to a cause of action for death or for injury to person or to personal property or growing crops shall be presented not later than six months after the accrual of the cause of action. A claim relating to any other cause of action shall be presented not later than one year after the accrual of the cause of action.. (Gov. Code § 911.2.) B. Claims roust 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 clainis must be filed against each public entity. E. Fraud. See penalty for fraudulent claims,Penal Code Sec. 72 at the end of this form. ■■&aaa**"aaaaa a 2t0a0aaaa a a a a aaaaa aa as Revenue an an rr■■w+�ra�ratttrAaarar; RE: Claim By: Reserved for Clerk's filing stamp � 'f ., 3 Against the County of Contra Costa or } ED OCT 29 2GO4 District} (Fill in the name) } IrtEFtK BOAR?OF SUPE RV3SORS r r r 7,1 OSTA CO. } The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named district in the sum of Q and in support of this claim represents as follows: 1. When did the damage or injury occur? (Give exact date and hour) 3o- Cm I I ' 9 -T.rn e.� 2. Where did the damage or injjjury occur? (Include city and county) Ax/t 3. How did the damage or injury occur? (Give full details;use extra paper if required) 14 4. What particular act or omission on the part of county or district officers, servants, or employees caused the injury or damage? ;,,5 ' � ` V041 C le, 5 What are the names of county or district officers, servants, or employees causing the damage or injury? s 6. What damage or injuries do your claim resulted? (Clive 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 8. Names and addresses of witnesses,doctors, and hospitals: IVIA 9. List the expenditures you made on account of this accident or injury: DATE TIME AMOUNT was wa i s a i a it ) Gov. Code Sec. 910.2 provides"The claim shall be )signed by the claimant or by some person on his behalf." 1 SEND NOTICES TO: (Attorney) 1 Name and address of Attorney ) (Claim Signature) A4'c (Address) ) ) Telephone No. )Telephone No. r 013 2 a■Klaaaaai■■aaaaowns noon Xmas raaliaaaialaaaYlYirlaialiaaaia■aiiaialailalataaaasiaa!■al PUBLIC RECORDS NOTICE: Please be advised that this claim form, or any claim filed with the County under the Tort Claims Act, is subject to public disclosure under the California Public Records Act. (Gov. Code, §§ 6500 et seq.) Furthermore, any attachments,addendums,or supplements attached to the claim form, including medical records, are also subject to public disclosure. a ria"among sYlss■*so was■alasllrrairarrss■srarYrliaraarlr■sass:KaailaaaYan*sun***a Kauai 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 dollars ($1,000.00), 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. Date: 1011 112004 12:21 PM Estimate ID: 1203 Estimate Version: 0 Prel€minary Proms ID: ROSS A/B ROSS AUTO} BODY 10781 SAN PABLO AVE.EL CERRITO,CA 94530 (510)$24.6176 Fax: (510)526.8190 Tau 111: 68 0209415 BAR* AC145793 EPA* CAL000056841 Damage Assessed By: CLIVE FLOSS Deductible: UNKNOWN Owner JASON PERRY Mitchell Service: 916489 Description: 1981 Buick Regal Custom Body Style: 4D Sed Drive Train: 3AL€nj 6 Cyl AO Line Entry Labor Line€tarn► Part Type/ Dollar Labor Item Number 'Type Operation Description � Part Number Amount Unita 1 609760 BOY REMOVEIREPLACE WHEEL Remanufactured 179.00* 0.3 2 822940 REF BLEND L REAR DOOR OUTSIDE C 0.9 3 $2660 BDY REMOVEIREPLACE L QUARTER OUTER PANEL 10208718 GM PART 556.86 13.8 6 4 AUTO REF REFINISH L QUARTER PANEL OUTSIDE C 2.4 5 AUTO REF REFINISH L ADD FOR PILLAR c 0.5 6 AUTO REF REFINISH L QUARTER PANEL EDGE C 0.5 7 826890 BOY REMOVEIREPLACE L QUARTER FUEL DOOR 10236262 GM PART 47.32 INC a 827140 BDY REMOVEIREPLACE L QUARTER WHEEL OPENING MLDG 10091141 GM PART 70.50 INC 9 827280 BDY REMOVE/REPLACE L QUARTER NAMEPLATE 10156895 GM PART 20.52 INC 10 828530 MCH ALIGN REAR SUSPENSION -M 1A 11 AUTO REF AWL OPR CLEAR COAT 1.6 12 933003 REF ADD'L OPR TINT COLOR 0.5* 13 933018 REF ADD'L OPR MASK FOR OVERPRAY 5.00* 0.2* 14 AUTO ADD"L COST PAINTIMATERIALS 204.80* 15 AUTO ADUL COST HAZARDOUS WASTE DISPOSAL 5.00* *-Judgement Item #-Labor Note Applies C-included In Clear Coat Calc ESTIMATE.RECALL NUMBER: 101111200412:21:04 1203 UltraMate is a Trademark of Mitchell International Mitchell Data Version: SEF!04—A Copyright(C)1994-2003 Mitchell international Page 1 of 2 UltraMate Version: 5.0.024 All Rights Reserved Date: 10{711200412:21 PM Estimate ID. 1203 Estimate Version: 0 Preliminary Profile ID: ROSS A1B Add`I Labor Sublet 1. Labor Subtotals Units Rate Amount Amount Totals 11. Part Replacement Summary Amount Body 13.8 68.00 0.00 0.00 938.40 Taxable Parts 874.00 Refinish 6.6 68.00 5.00 0.00 453.60 Sales Tax 8.250% 72.11 Mechanical 1.4 65.00 0.00 0.00 118.00 Total Replacement Parts Amount 948.11 Non-Taxable Labor 1,511.20 Labor Summary 21.8 1,511.20 M. Additional Costs Amount IV. Adjustments Amount Taxable Costs 204.80 Customer Responsibility 0.00 Sales Tax @ 8.250% 16.90 Non-Taxable Costs 5.00 Total Additional Costs 226.70 1. Total Labor: 1,511.20 11. Total Replacement Parts: 946.11 Ill. Total Additional Costs: 226.70 Gross Total: 2,684.01 IV. Total Adjustments: 0.00 Net Total: 2,684.01 This is a preliminary estimate. Additional changes to the estimate may be rsEacred for the actual repair. I HEREBY AUTHORIZE ROSS AUTO BODY TO COI!tV-NCE REPAIRS ON MY VEHICLE PER THIS ESTIMATE. SIGNED DATE ESTIMATE RECALL NUMBER: 101111200412:21:04 1203 UltraMats is a Trademark of Mitchell International Mitchell Data Version: SEP'04_A Copyright(C)1994-2003 Mitchell International Page 2 of 2 UltmMate Version: 5.0.024 All Rights Reserved Date: 10/18/2004 04:14 PM Estimate 10: 3181 Estimate Version: 0 Preliminary Profile ID: Mitchell HILLTOP ESWICK PONTIAC GSC 3230 Auto Plaza Richmond,CA 9480$ (510)222.4'141 Fax: (510)222-4309 BAR M AH190863 EPA#: CAd004771168 Damage Assessed By: Gary Leucht Deductible: UNKNOWN Owner JASON PERRY Address: 4911 FRAY AVE.RICHMOND,CA 94804 Telephone: Work Phone: (510)932.1870 Home Phone: (510)529-2764 Mitchell Service: 918489 Description: 1991 Buick Regal Custom Body Style: 40 Bed Chive Train: 3.81.lnj 6 Cyi AO VIN: 2G4W854L0M1878197 "All Crash pmts can this estimate aro "" Now Original Equipment " manufacturer parts,unless otherwise specified. Parts doscribed as rechromaed,romanufactured or,reconditioned are considered "Ptabuilt"parts. Crash parts described as "Quality Replacement Parts" are non-original equipment manufacturer aftermarket new parts. Lins Entrry Labor Line Rem Part Type/ Dollar Labor Item Number Type Operation Description Part Number Amount Units 1 809760 BOY REMOVEIREPLACE WHEEL Remanufactured 200.00" 0.3 2 $22940 REF BLEND L REAR DOOR OUTSIDE C 0.9 3 800321 BOY REMOVEIINSTALL L REAR LWR REVEAL MOULDING 0.7 0 4 $23460 BOY REMOVEIINSTALL L REAR LWR DOOR MOULDING 0.3 5 800569 BOY REMOVEIINSTALL L REAR DOOR TRIM PANEL INC 6 $24152 BOY REMOVEIINSTALL L REAR OTR DOOR HANDLE 0.8 # 7 024240 BOY REMOVEANSTALL L REAR LOCK MODULE INC # 8 900500 MCN* REMOVEIREPLACE VALVE STEM @ 1.00 EA New 0.0* 9 900500 MCH* ALIGN 2 WHEEL ALIGNMENT Sublet 75.00* 0.0* 10 828500 BDY REPAIR L QUARTER OUTER PANEL Existing 10.0*# 11 AUTO REF REFINISH L QUARTER PANEL OUTSIDE C 2.4 12 826750 BDY REPAIR L OTR QUARTER WHEELHOUSE PANEL Existing 2.0* 13 838890 BOY REMOVEIREPLACE L QUARTER FUEL DOOR 10236262 GM PART 47.32 0.3 14 W140 DDY REMOVE/REPLACE L QUARTER WHEEL OPENING MLDG 10094141 GM PART 70.50 0.3 15 8272$0 BOY REMOVE/REPLACE L QUARTER NAMEPLATE 10166895 GM PART 25.40 0.2 16 800966 GLS REMOVEANSTALL L QUARTER GLASS 1.3 # 17 800408 BDY REMOVE/INSTALL L REAR LAMP ASSY 0.3 # 18 831870 BOY OVERHAUL REAR COVER ASSY 2.5 # 19 8319$0 BOY REPAIR REAR BUMPER COVER Existing 1.0*# 20 AUTO REF REFINISH REAR BUM COVER C 2.3 21 AUTO REF ADD`L OPR CLEAR COAT 1.6 22 933003 REF ADWL OPR TINT COLOR 0.6* ESTIMATE RECALL NUMBER- 10/18/200418:14.11 3181 UB.raMate is a Trademark of Mitchell International M Itchell Data Version. OCT_04_A Copyright(C)1094-2003 Mitchell International Page 1 of 2 UOraMate Version: 5.0.023 All Rights Reserved Data: 1011812004 04:14 PM Estimate ID: 3181 Estimate version: 0 Preliminary Profile iia: Mitchell 23 933005 REF* ADI}"L OPR RESTORE CORROSION PROTECTION 8.00* 0.3* 24 933018 REF ADIYL OPR MASK FOR OVERSPRAY 5.00* 0.2* 25 AUTO ADD'L COST PAINT)MATERIALS 231.00* 26 AUTO A:DD'L COST SHOP MATERIALS 26.00* 27 AUTO AWL COST HAZARDOUS WASTE UiSPOSAL 5.00* Judgement Item #-Labor Note Applies C -Included in Clear Coat Calc Add°i Labor Sublet 1. Labor Subtotal* Units Rate Amount Amount Totals i1. Part Replacement Summary Amount Body 18.7 "70.00 11.110 0.00 1,309.00 Taxable Parts 343.22 Refinish 8.2 711.00 13.00 0.00 587.00 Sales Tax @ 8.260% 28.32 Class 1.3 70.00 0.00 0.00 91.00 Mechanical 0.0 100.00 0.00 75.00 75.00 Total Replacement Pads Amount 371.54 Non-Taxable Labor 2,062.00 Labor Summary 28.2 2,062.00 Ill. Additional Costs Amount IV. Adjustments Amount Taxable Costs 257.00 Customer Responsibility 0.00 Sales Tax 8.250% 2120 Non-Taxable Casts 5100 Total Additional Costs 283.20 1. Total Labor: 2,062.00 H. Total Replacement Parts: 371.54 Ill. Total Additional Costs: 283.20 Cross Total: 2,716.74 IV. Total Adjustments, 0.00 Net Total: 2,716.74 This a preliminary estimate. Additional changes to the 22timats m#1 be rams#red for the actual repair, ESTIMATE RECALL NUMBER: 10MSM00416:14:11 3181 UitraMaft Is a Trademark of Mitchell international Mitchell Data version: OCT-"-A Copyright(C)1884-2003 Mitchell International Page 2 of 2 UltraMate Vemlon: 5.0.025 All Rights Reserved CLAIM /�. BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY f BOARD ACTION:NOVEMBER.'30, 2004 Claim Against the County, or District Governed by ) the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to ) The copy of this document mailed to you is your California Government Codes. } notice of the action taken on your claim by the Board of Supervisors. (Paragraph IV below), given Pursuant to Government Code Section 913 and 915.4. Please note all"Warnings". AMOUNT: $300,000-00 ... ..: . ... ....... ...: ........ , CLAIMANT: RAFAEL P.. NAZARIO ATTORNEY: DOMINICK FRANCO DATE RECEIVED: NOVEMBER 01, 2004 ADDRESS: DOMINICK J. FRANCO BY DELIVERY TO CLERK.ON: NOVEMBER 01, 2004 BONFILIO & FRANCO 1375 SUITER ST. , SUITE 302 BY MAIL POSTMARKED: OCTOBER 30, 2004 SAN FRANCISCO, CA.94109 FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN SWEE E rk Dated: NOVEMBER 01, 2004 By: Deputy II. MOW County Counsel. TO: Clerk of the Board of upa..isors claim complies substantially with Sections 910 and 910.2. t ( } 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 ofthe Board TO: County Counsel (1) County Administrator(2) ( ) Claim was returned as untimely with notice to claimant(Section 911.3). IV. ARD ORDER: By unanimous vote of the Supervisors present: ( This Claim is rejected in full. { } Other: I certify that this is a true and correet'copy of the Board's Order entered in its minutes for this date. Dated-A40 014:'' JOHN SWEETEN, CLERK, By , Deputy Clerk WARNING(Gov. code se on 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. *For Additional Warning See Reverse Side of This Notice. 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: deo voh-4 �f JOHN SWEETEN, CLERIC By Deputy Clerk 10/29, 2004 __ CONTRS? COSTO COU4TY CLEF V OF THE BOARD OF SUPERVISORS OF CONTRA COSTA COUN'T'Y INS.TRVCTIQNS,TO CLAI A, A claire relating to a cause of action for deatli or for injury to person car TO personal property or growing craps shall be presented not later than six months after the accrual of the cause of' action. A claim relating to any other cause of-action shall be presented not later the one year after the accrual of the cause of action. (Gov. Code § 911-1) B. Cl3inzs must be filed Aith the Clerk of the- Board of Supervisors at its office in Roam 105. County Administration Building, 551 Pine Street, Martinez, CA 94553. C. if claim is against a district governed by the Board of Supervisors, rather diaz the t`Ccunry, the name of the District should be filled in. 1D. If the claim is against more tim one pudic entity, separate claims must be filed against each public entity. E, f rain!. See penalty for fraudulent claims,penal Code Sec. 72 at the end of this form. iFaili�71113/••���* *so*sa ago$S0161005 I U♦*ago"•o■if KY a■a&***am.*if*a*a#*a** i? RE Claim By: Rear*6Esfilin. stamp RAFAEL P. NAZARIO ?----------------- NOV012004 A �t the b'ount'y of Contra Costa or j G;.ERK 80AFQ OF SUPEROSORS, C0 TRA COSTA REGIONAL MEDICAL MINTRA '? tACo, CENTER District) (Fill in the name) } The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named district in the stun.of i1,ti ;1 :Yn rcpr,- tits a� 'nliovac 1. When did the damage or injury occur? (Give exact date and hour) May ll, 2004 8 : 30 am. Z. Where did the damage or injury occur? (Include city and county) Martinez, California, County of Contra. Costa 3. How did the damage or injury occur? (Give full details;use extra paper if required, Negligent surgery to my right ear resulting in paralysis of my face, 4. What particular act or omission on the part of county or district officers,, servants, or etmplovees caused the injury or damage? +Negligence in performing surgery. 5 What are the names of county or district officers, servants, or employees causing the damage or igJury"? Thomas White, M.D. and other county employees unknown to me at this time. 10/29/2004 1,-3 5 3 CONTRA COSTR COLINTY CLE=RK OF THE 4 91415929-71-22tdC. 1 i b. What damage or injuries do your claim resulted?. (Crve full extent of injuries or damagez claimed. Attach two estimates for auto damage.) Paralysis of the right side of my face. 7. '-low was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage,) The amount was computed by calculating the possible amount of future medical expenses and pain and. suffering. 8, Names and Addresses of witnesses,doctors,and hospitals: Unknown at this time. 9. List the expenditures you made on account of this accidom or injury: HATE TYME AMOUNT Will incur future medical expenses in an amount unknown at-this time. •aaaawkaaataaaa a**$**a•aaaaaaeaaaa ala MRaaa a*****aatl aaaat aaaa#laaa■r raa•son a a evIva II } Gov. Code Sec. 910.2 provides"The claim shall be si ed by the claimant or by some person on his beh SEND NOTICES TCI: fAttota Narne and address of Attorney m. Dominick J. Franco } 4 mant'S Sign re} �. 1375 BonfSut & Franco } Ralfael Nazario, c/o Dominick. Franco 2375 Sutter St. , Suite 302 San Francisco, CA 94109 }- 1375 Sutter St. Suite 302- } (Address) } San Francisco, CA 94109 } Iselephon a`v';� 415 929-4900 ;? lepbove'v'o, 415.929-4 ■traaaeaaasaaaataaaaaaaaa*ararasraaaai�rarssssta aaa srcteraaa�0eawreaaat alae oast!apt li s5tt PUBLIC RECORDS NOTICE: Please be advised that this claim form, or any claixri filed with the County tinder the Ton Claims Act, is subject t(- public disclosure under the California Public Records Act. (Gov. Cade, §§ 6500 et seq.) Furthermore, ani attachments,addandurms,or supplements attached to the claim form, inc#riding medical records, are also subject{, public disclosure. naattttafafaMaaiaaaiatlrtwMaaaiaaaeaetaailitaaeaaiaaa•eaaaa�eeeleaaaaaaaeaaaaaaatlMa•haat+ 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, it to any county, city, or district board or eafricer, 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 dollars M,000.04)_ or by both such imprisonment and fine, or by imprisonment in the state prison, by a, fine of!tett exceeding;ten thousand dollars ( 10,000),or by boat such imprisonment and fine. Bt)NFIL10 & FR.ANCO Attorneys at Law Telephone.(415)929-4900 1875 Sutter Street,SuiteS02 Fax(415)929-9222 San Francisco,California 94109-5438 October 29, 2004 Clerk of the Board of Supervisors County of Contra Costa County Administration Building, Rm 106 651 Pine Street Martinez, CALIFORNIA 94553 RE: RAFAEL NAZARK} ENCLOSURE(S): Claim Form The above is provided to you for the following: { X ) Please file and return a filed-endorsed copy in the envelope provided. ( ) Please present for signature and return in the envelope provided. { ) Please acknowledge receipt and return in the envelope provided. ( ) Other: Sincerely, { _.j DOM NICK J. FRANCO CLAIM f 7 BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION:NOVWIBF-R 30, 2004 Claim Against the County, or District Governed by ) the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section refere#es.ate ) The copy of this document mailed to you is your California Government Codes. }>' notice of the action taken on your claim by the Board of Supervisors. (Paragraph IV below), given Pursuant to Government Code Section 913 and 915.4. Please note all"Warnings". AMOUNT: $1,830.99 plus $160.00 Car rental. CLAIMANT: RHONDA RHINES ATTORNEY": UNKNOWN DATE RECEIVED: NOVEMBER 01, 2004 ADDRESS: 5796 CUTTER LOOP BY DELIVERY TO CLERK ON: NOVEMBER 01, 2004 DISCOVERY .BAY, CA 94514 HAND DELIVERED BY MAIL POSTMARKED: FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN S`VYEETE Dated: NOVIN ER 01,,. 2QQ4_ By: Deputy IT WO—M: County Counsel TO: Clerk of the Board of Supervisors ( This claim complies substantially with Sections 910 and 910.2. s ( ) This Claim PAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot acct 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 311.3). ( ) Other: bated: 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 311.3). 1��his ORDER: By unanimous vote of the Supervisors present: 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 vt100em ,r,, JOHN SWEETEN, CLERK,By f , Deputy Clerk WARNING(Gov. code se6tion 913) Subject to certain exceptions, you have only six(6)months from the date this notice was personally served or depositer 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. *For Additional Warning See Reverse Side of This Notice. 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' Mai ZML4 JOHN SWEETEN, CLERK By Deputy Clerk BOARD OF SUPERVISORS OF CONTR t COSTA COUNTY INSTRUCTIONS TO CLAIMANT A A claim relating to a cause of action for death or for injury to person or to personal property or growing crops shall be presented not later than six months after the accrual of the cause of action. A claim relating to any other cause of action shall be presented not later than one year after the accrual of the cause of action. (Gov. Code § 911.2.) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Roo 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. •Dean Soso sss*No 0ssrsssrsssssassssssssssswages f■sssaas*sssssssssssssssrwssssss RE: Claim By. Reserved for Clerk's filing stamp RECEIVED Against the County of Contra Costa or } NOV0 1 200 4 _ District) """P � OARD (Fill in the name) ) COO UPERVISO%. TSTA CO The mindersigned claimant herebymake, sir im Inst the County of Contra Costa or the above-nameddistrict in the surra of and in support of this claim represents as follows: L.- 1. When did the.damage or injury occur? (Give exact date and hour) q ,0,c (_)��_ co , 2. Where did the damage or injury occur? (I;n�clude twity and county) 3. How did the damage or injury occur? (Give full details; use extra paper if required) 4. What'particular act or omission on the past of county or district officers. servants, or t employees caused the injury or damage? -Tk ( c be, i ik � ' itiZt"s3 5 What are the names of county or district officers, servants, or employees causing the damage or injury? AbqnAl Mr 6. What damage or injuries do your claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage.) ,O�Jk' r�-\ote atto C k"e A 7. How was 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 thif.accident or injury. DATE TIME AMOUNT aaaaaaa■aaaaaaaaaaarraaaaaa■■a0aaarr/aaarrarreaaeaaraaaaaaarararraaaaaraaraaa■/area ) Gov. Code Sec. 910.2 provides "The claim shall be ) signed by the claimant or by some person on his behalf." SEND NOTICES TO: (Attorney) ) } €y ,a; Name and address of Attorney - L (Claimant's Signature) Loop (Address) Uts c 0'�Vft--A } "-J Telephone No. } Telephone No. 0 + ,aaaaaaa5a2a0a■aseaaaaa•aaaaaaaaasararraaaaaaur/■arae/ raaaSam was aaarraara aaaaasae 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 dollars ($1,000.00), or by both such imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ($10,000), or by both such imprisonment and fine. r i Cuts, a5, ; _ t A r �' _ b _ _ _ CLASSIC AUTO BODY 1401 AUTO CENTER DRIVE WALNUT CREEK, CA 94596 PHONE•. {925} 938-3131 FAX: {925} 938-0718 CD LOG NO 4652-1 DATE 10/18/04 SHOP: CLASSIC AUTO BODY !NSP DATE: 10/18/04 ADDRESS: 1401 AUTOCENTER DRIVE CONTACT: TIM KAMM CITY STATE: WALNUT CREEK, CA PHONE 1 : (925) 938-3132 ZIP: 94597- FAX: {925} 938-0718 OWNER: RHINES, BRAD HOME PHONE: {925} 634-6174 LIC : 5EHC115 STATE: CA VIN: 1HGCG564XWA016923 BODY COLOR: MILEAGE: CONDITION: ACCTNG CTL : *=USER-ENTERED VALUE E=REPLACE OEM NG=REPLACE NAGS EC=REPLACE ECONOMY UC=RECONDITIONED PRT UM-REMAN/REBULLT PRT EU=REPLACE SALVAGE EP=REPLACE PXN PC=PXN RECONDITIONED PM=PXN REMAN/REBUILT TE=PARTL REPL PRICE ET=PARTL REPL LABOR IT=PARTIAL REPAIR I=REPAIR L=REFINISH BR=BLEND REFINISH TT=TWO-TONE CG=CHIPGUARD SB=SUBLET N=ADDITIONAL LABOR RI=R&I ASSEMBLY P=CHECK AA=APPEAR ALLOWANCE RP=RELATED PRIOR UP=UNRELATED PRIOR 1998 HONDA ACCORD LX 4DOOR SEDAN 4CYL GASOLINE 2 . 3 VTEC CODE: H1263B/A OPTNS B/24BCDIM OPTIONS: TWO-STAGE - EXTERIOR SURFACES TWO-STAGE - INTERIOR SURFACES ELEC REMOTE CONTROL MIRRORS POWER DOOR LOCKS POWER WINDOWS AIR CONDITIONING CRUISE CONTROL OP GDE MC DESCRIPTION MFG. PART NO. PRICE AJ$ B% HOURS R E 0131 APPLIQUE, FRT DOOR F LT 72470S84AOO 30. 83 0. 2 1 RI 0259 MLDG, FRONT DOOR SID LT R&I ASSEMBLY 0.4 1 E 0229 01 MIRROR,OUTER R/C LT 76250S84A21ZB 151 . 68 0 . 3 1 L 0229 13 MIRROR,OUTER RIC LT REFINISH 1. 4 4 E 0215 GLASS, FRONT DOOR T LT 7335OS84AOO 145. 98 1 . 0 1 I 0287 DOOR SHELL, REAR LT REPAIR 1 . 0*1 L 0287 DOOR SHELL,REAR LT REFINISH 2 . 5 4 RI 0423 W/STRIP, RR DOOR LOW LT R&I ASSEMBLY 0.2 1 RI 0333 MLDG,REAR DOOR BELT LT R&I ASSEMBLY 0.3 1 RI 0335 MLDG,REAR DOOR SIDE LT R&I ASSEMBLY 0 . 4 1 E 0337 APPLIQUE ASSY,REAR LT 72970S84AO0 31. 73 0. 2 1 E 0295 GLASS,REAR DOOR T LT 73450S84A00 129. 72 0. 9 1 RI 0305 01 HANDLE, RR DOOR OUTE LT R&I ASSEMBLY 0 . 5 1 I 0389 PNL ASSEMBLY,QUARTE LT REPAIR 0. 5*1 L 0389 PNL ASSEMBLY,QUARTE LT REFINISH 2 . 9 4 PAGE i 1998 HONDA ACCORD LX 4DOOR SEDAN CD LOG NO 46552-1 RI 05333 TAILLAMP ASSEMBLY,O LT R&I ASSEMBLY 0 . 3 1 L M14 CORROSION PROTECTION REFINISH 10. 00* *4* M15 COLOR TINT REFINISH 0 . 5*4* N M17 COVER CAR EXTERIOR ADDNL LABOR OPERA 5. 00* 0. 3*4* N M60 HAZARD. WSTE. REM. ADDNL LABOR OPERA 5 . 00* L N M66 COLOR, SAND & BUFF ADDNL LABOR OPERA N ROPE REAR WINDOW ADDNL LABOR OPERA 0. 5*1* 22 ITEMS MC MESSAGE (S) 01 ""ALL DEALER FOR EXACT PART NUMBER PRICE 13 INCLUDES 0. 6 HOURS FIRST PANEL TWO-STAGE ALLOWANCE FINAL CALCULATIONS & ENTRIES GROSS PARTS 489. 94 OTHER PARTS 20. 00 PAINT MATERIAL 220 . 40 PARTS & MATERIAL TOTAL 730 . 34 TAX ON PARTS & MATERIAL @ 8 .250% 60 .25 LABOR RATE REPLACE HRS REPAIR HRS 1-SHEET METAL 68 . 00 4. 7 3. 0 523. 60 2-ME$'-'H/ELEC 92. 00 3-FRAME 68. 00 4-REFINISH 68 . 00 7 . 3 0. 3 516. 80 5-PAINT MATERIAL 29. 00 LABOR TOTAL 1, 040. 40 SUBLET REPAIRS TOWING STORAGE GROSS TOTAL 1, 830. 99 NET TOTAL 1, 830. 99 ADP SHOPLINK UB275 ES CD LOG 4652-1 DATE 10/18/04 01 : 00:30PM R6. 35 CD 09/04 HOST LOG (C) 1.998 - 2004 ADP CLAIMS SOLUTIONS GROUP, INC. 1 . 6 HRS WERE ADDED TO THIS EST. BASED ON ADP TWO-STAGE REFINISH FORMULA. -------------------------------------------------- TEST PAGE 2 (0M {{ LO 19 cCv 10/13/2004 at 03 :07 PM Job Numb ft 11 73659 ffiftaftaII co(0 LO LO BRENTWOOD ACJTOBODY Federal ID #:942958593 :i 4535 O'Hara Avenue Q E Brentwood, CA 94513 � } (925)634-6366 Fax: (925) 634-2593 C d PRELIMINARY ESTIMATE G � :3 u3 C) >°' Written By: ,Ton Wilson 0 d< Adjuster: 115 d 9 © a Insured: BRAD RHINES Claim # iU; L Owner. BRAD BRINES Policy # �} m Address: 5796 CUTTER LOOP Deductible: DISCOVERY BAY, CA 94514 Date of Doss: Day: (925) 634-6174 Type of Loss: Business: (53.0) 247-2526 Point of Impact: 10. Left Front Pil Inspect BRENTWOOD AUTOBODY Business: (925) 634-6366 Location: 4535 O'Hara Avenue Brentwood, CA 9451.3 Insurance Company: Days to Repair 1998 HOND ACCORD LX 4--2 .3L-FI 4D SED SILVER Int:GRAY VIN: IHGCG564XWA016923 Lic: 5EHC115 CA Prod Date: 09/1997 Odometer: Air Conditioning Rear Defogger Tilt Wheel Cruise Control Intermittent Wipers Body Side Moldings Dual Mirrors California Emissions Clear Coat Paint Metallic Paint Power Steering Power Brakes Power Windows Power Locks Power Mirrors AM Radio FM Radio Stereo Driver Air Bag Passenger Air Bag Cloth Seats Bucket Seats Automatic Transmission overdrive Deluxe Wheel Covers ------------------------------------------------------------------------------- NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT -----------------------------------w-------------------------------------------- 1 REAR 'BUMPER. 2 R&I R&I bumper cover 0.8 3 REAR LAMPS 4 R&I LT Lens & housing 0.4 5 QUARTER PANEL 6* Rpr LT Quarter panel 0.5 2.2 7 Add for Clear Coat __ 0.9 8 Refn Fuel door 0.3 9 Add for Clear Coat 0.1 10 R&I LT Pillar molding LX, EX, SE 0.3 11 ROOF 12# Blnd LT outer roof pillar 1.0 13* R&I LT Roof molding 0.3 14 R&I LT Drip molding LX, EX, SE 0.3 1 10/13/2004 at 03 :07 PM Jab Number. 73659 PRELIMINARY ESTIMATE 1998 HOND ACCORD LX 4-2.3L-FI 4D SED SILVER Int:GRAY -------------------------------------------------------------------------------- NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT ---------------------------------------------------_-_---_-----_-_--------------- 15# R&I Rope back glass reveal mldg 0.4 16# R&I Rope windshield reveal mldg 0.4 17 REAR DOOR 18* Rpr LT Dear shell 00.5 2.0 19 Overlap Major Adj . Panel -0.4 20 Add for Clear Coat 0.3 21 Repl LT Pillar melding US built 1 31.73 0.3 22 R&I: LT Belt w'strip LX, EX, SE 0.3 23 R&I LT Body side mldg DX, LX 0.3 24 R&I LT Handle, outside LX, EX, SE 0.4 USA built silver 25 R&I LT R&I trim panel 0.4 26 FRONT DOOR 27 Repl LT Pillar molding US built 1 30.83 0.2 28 Repl LT Mirror assy LX, EX, SE 1 151.68 0.4 0.5 silver 29 Add for Clear Coat 0.1 30 R&I LT Belt w"strip LX, EX, SE 0.3 31 R&I LT R&I trim panel 0.4 32# HAZARDOUS WASTE REMOVAL 1 5.00 X 33# COVER CAR 1 10.00 T 0.2 34# TINT COLOR 1 0.5 35# COLOR SAND & RUB 1 1.0 -------------------_-----_-----_---_--_-_----_--------_-_----_-_-_--_-------_--- Subtotals =_> 229.24 8.4 7.2 Parts 214.24 Body Labor 8.4 hrs Q $ 68.00/hr 571.20 Paint Labor 7.2 hrs @ $ 68.00/hr 489.60 Paint Supplies 7.2 hrs G $ 30.00/hr 216.00 Sublet/Misc. 15.00 --_-------------------•----_------_---_----------__-- SUBTOTAL $ 1506.04 Sales Tax $ 440.24 @ 8.2500% 36.32 ----------------------------------------------------- GRAND TOTAL $ 1542.36 ADJUSTMENTS: Deductible 0.00 ----------------------------------------------------- CUSTOMER PAY $ 0.00 INSURANCE PAY $ 1542 .36 2 10/13/2004 at 03 :07 PM Job Number: 7'3659 PRELIMINARY ESTIMATE 1958 HOND ACCORD LX 4-2.3L-FI 4D SED SILVER Int:GRAY FOR YOUR PROTECTION CALIFORNIA LAW REQUIRES THE FOLLOWING TO APPEAR ON THIS FORM: ANY PERSON WHO KNOWINGLY PRESENTS FALSE OR FRAUDULENT CLAIM FOR THE PAYMENT OF A LOSS IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN STATE PRISON. THE FOLLOWING IS A LIST OF ABBREVIATIONS OR SYMBOLS THAT MAY BE USED TO DESCRIBE WORK TO BE DONE OR PARTS TO BE REPAIRED OR REPLACED: MOTOR ABBREVIATIONS/SYMBOLS: D=DISCONTINUED PART A=APPROXIMATE PRICE LABOR TYPES: B=BODY LABOR D=DIAGNOSTIC E=ELECTRICAL F=FRAME G=GLASS M=MECHANICAL P=PAINT LABOR S=S'T'RUCTURAL T=TAXED MISCELLANEOUS X=NON TAXED MISCELLANEOUS PATHWAYS: ADJ=ADJ'ACEN'T' ALGN=ALIGN A/M=AFTERMARKET BLND=BLEND CAPA=CERTIFIED AUTOMOTIVE PARTS ASSOCIATION D&R=DISCONNECT AND RECONNECT EST=ESTIMATE EXT. PRICE=UNIT PRICE MULTIPLIED BY THE QUANTITY INCL=INCLUDED MISC®MISCELLANEOUS NAGS=NATIONAL AUTO GLASS SPECIFICATIONS NON-ADJ=NON ADJACENT O/H=OVERHAUL OP=OPERATION NO=LINE NUMBER QTY=QUANTITY QUAL RECY=QUALITY RECYCLED PART QUAL REPL=QUALITY REPLACEMENT PART COMP REPL PARTS=COMPETITIVE REPLACEMENT PARTS RECOND=RECONDITION REFN=REFINISH REPL=REPLACE R&I=REMOVE AND INSTALL, R&R=REMOVE AND REPLACE RPR=REPAIR RT=RIGHT SECT=SECTION SUBL=SUBLET LT=LEFT W/O=WITHOUT W/_=WITH/- SYMBOLS: ##=MANUAL LINE ENTRY *=OTHER [IE. .MOTORS DATABASE INFORMATION WAS CHANGED] **=DATABASE LINE WITH AFTERMARKET N=NOTES ATTACHED TO LINE. MQVP=MA-NUFACTURER'S QUALIFICATION AND VALIDATION PROGRAM. Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide AR04422 Database Date 09/2004, CCC Data Date 09/2004, and the parts selected are OEM-parts manufactured by the vehicles Original Equipment Manufacturer. OEM parts are available at OE/Vehicle dealerships. Asterisk (*) or Double Asterisk (**) indicates that the parts and/or labor information provided by MOTOR may have been modified or may have come from an alternate data source. Tilde sign (-) items indicate MOTOR Not-included Labor operations. Non-Original Equipment Manufacturer aftermarket parts are described as AM, Qual Repl Parts or Comp Repl Parts which stands for Competitive Replacement Parts. Used parts are described as LKQ, Qua'. Recy Parts, RCY, or USED. Reconditioned parts are described as Recon. Recored parts are described as Recore. NAGS Part Numbers and Prices are provided by National Auto Glass Specifications, Inc. Pound sign (4) items indicate manual entries. Some parts that are described as Recon. may be OE Surplus parts or other OE parts offered at a special pricing discount. For further clarification please review the Suppliers List attached to this estimate, or consult the appraiser or estimator. CCC Pathways - A product of CCC information Services Inc. 3