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HomeMy WebLinkAboutMINUTES - 12202005 - C.21 CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION: DEC. 20, 2005 Claim Against the County, or District Gov�emed 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 jjo? �� yid a D Board of Supervisors. (Paragraph IV below), gives 8U Pursuant to Government Code Section 913 and NOV 2w 3 2005 915.4. Please note all "Warnings". AMOUNT: UNKNOWN ATUTHISCTIMEi MARTINEZ CALIF. CLAIMANT: JOY STOWELL ATTORNEY: UNKNOWN DATE RECEIVED: NOV. 23, 2005 ADDRESS: 16401 - 301 SAN PABLO AVENUE BY DELIVERY TO CLERK ON: NOV. 231 2005 SAN PABLO, CA 94806 RECEIVED FROM RISK BY MAIL POSTMARKED: MANAGEMENT FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. NOVEMBER 23 2005 JOHN SWE Jerk Dated: ' By: Deputy II. FROM: County Counsel. TO: Clerk of the Board of Supe isors ( tis claim complies substantially with Sections 910 and 910.2. O This Claim FAILS to comply substItially 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). O Other: Dated: fir' �"�`� ' By: M Awa - Deputy County Count I11. 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 unani Ious vote of the Supervisors present: This Claim is rejected in full. O Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: 0/~AVd&W'g&ACJUH1N SWEETEN, CLERIC;By Deputy Clerk WARNING (Gov. codes 'ct en 913 Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposil in (lie 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 1 declare under penalty of perjury,that I I 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 Post .Se 'ce in Martinez, California, postage full prepaid a certified copy of this Board Order and Notice to Claiman addressed the gkimant as shown above. Dateda� v�s +�' mf JOHN SI EETEN, CLERK Deputy Clef r I J � ' SEP-12-2005 09:27 CCC RISK MANAGMENT 925 335 1421 P.02 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 claimrelating 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 bei ed 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. auar■aaaa■aaa■aaraar■al■a■■■aazaa.aas 0aa■■a■a.a a■a a a a aaa a z a-aa aa■a0a RE: Claim By: Reserved for Clerk's filing stamp RECEIVE® NUV l 3 2005 Against the County of Contra Costa or ) CLERK BOgRD OF SUPERVISORS CONTRA COSTA CO. District) (Fill in the name) ) I 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: lUv K wv� at 4�L L When did the damage or injury occur? (Give exact date and hour) u` l01 2005 o ISpm 2. Wher�thedamaggte or injury occur? (Include city and county) ul pl , a 1 _ How did the damage or injury occur? (Give full details;use extra paper if required) 4. What particular act or omission on the part of county or district officers, servants, or employees r caused the injury or damage? 40&A.0—-b 2�0 ,,.v� � Ca� /"c��� a ti� � es o SEP=12-2005 13:47 CCC RISK MANAGMENT 925 335 1421 P.02/02 6. What damage or injuries do your claim resulted? (Give full extent of injuries or damages claimed. Attach two es ' ates for auto damage.) / �1 ,4 h 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 hosfVs rUl j=d ch nb QR- VtiCCau�_ IIZ eA 5.ql �Z3,L�l Pablm Cdti ? Cly 9�I�X/6 9. List��e expenditures you made on acco{wt of this accident or injury: DATE TIME AMOUNT •...■a■aam mamas a a OEM ommem■■m oris maml■amamau amoamaaau�mmr&smmea■amma mmm mag a.a..aa.as ) .Gov. Code Sec. 910.2 provides"The claim shall be signed by the claimant or by some person on his behalf." SEND NOTICES TO: (Attornevl 1 Name and address of Attorney ) ,, fillainfini's-Signature) Am& (Address) eA- 91-Iso-6 Telephone No. )Telephone No. ��� ! Yl 27 �J Rau mea a as as amssaa■a a■amm man&smme mea•■oss Rmaaasas RRauo aume■■msmasaoa&s■mama a aria Rain 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, §5 6500 et seq.) Furthermore, any attachments,addendums,or supplements attached to the claim form, including medical records, are also subject to public disclosure. ■masons somumemsmom ame lug mmaa Esse Samx4ass som&s■son som.mm&suua.aamaa.■as■*am a■a■■Xmas 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 line, 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. TOTRL P.02 #3. How did the damage or injury occur? The asphalt had fallen in and become uneven. Depending on the time of day and direction of the sun, the visibility of the sinking street is undetectable creating a hazard. It creates an optical illusion created by heat reflection, so that when I stepped on that area, I did not see that it had sunken in, and my foot twistedland down I went. I was completely immobile. A neighbor that was outside offered to lift me up, which he did. #6. What damage or injuries do you claim resulted? Right ankle with lateral tear and severe strain. Physically this has been the most painful,ongoing,life altering incident/injury of my life. The doctor recommended I take a week off work so that I could stay off my foot, but because I am my sole provider and have financial responsibilities, I told him I could only take one day off. And since I work in an office,I was able to set up a way to keep my foot up most of the day, although I was, at times, in excruciating pain(and I have a high pain tolerance). Since it is my right foot that is injured, it is unbearably painful to drive,because the position of the foot in order to push down the accelerator and apply the brake is extremely painful. Needless to say, this has caused another breach in my normal daily activities. I usually work until 2 or 3 pm daily,then do a volunteer work which involves going to peoples homes to which I need to drive. I drive to work daily but I have had to rely on others for my other activities. It has caused me anxiety and depression problems because I have not had the capacity to care for myself in a�normal way. And to top it off,I have not been able to sleep in my bed because I could not stand the pain of anything touching my foot, so my sleep has been affected. I had scheduled a weekend trip that I had to cancel because it would be too much walking in the airports for me. Yes,this has totally disrupted my life and caused me much pain and suffering. I understand that it takes a long time to be totally free of pain from others that have torn a ligament. #9. List the expenditures you made on account of this accident or injury: 9/12/05 Dr Snyder $15.00 9/13/05 Off Work $120.00 9/16/05 Dr Snyder $15.00 9/22/05 Ankle Compress $ 9.78 9/20/05 Dr Snyder $15.00 9/25/05 Ankle Stabilizer $ 19.47 9/26/05 Dr Snyder $15.00 10/10/05 Dr Snyder $15.00 11/14/05 Dr Snyder $15.00 CLAIM /f BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY (,j • / BOARD ACTION: DEC. 20, 2005 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 ���II Board of Supervisors. (Paragraph IV below), give► !!t1 Pursuant to Government Code Section 913 and NOV 2 3 2105 915,4. Please note all "Warnings". AMOUNT' $205.11 COUNTY MARTINEZ OUEL CALIF. CLAIMANT: JOHN F. GOUTARTE ATTORNEY: UNKNOWN DATE RECEIVED: NOV. 23, 2005 ADDRESS: 2310 TAPER ST. , BY DELIVERY TO CLERK ON: NOV. 23, 2005 PINOLE, CA 94564 r BY MAIL POSTMARKED: HAND DELIVERED FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. NOVEMBER 23 2005 _ I JOHN SWEE E Jerk Dated; By: Deputy II. FROM: County Counsel, TO Clerk of the Board of Sup isor's (LI'T' ris claim complies substantially wi Ih 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). O 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). O Other: Dated: �°� By: t/ln�gq 9�`'1 Deputy County Coun III. FROM: Clerk of the Board TOI: County Counsel (1) County Administrator(2) ( ) Claim was returned as untimely with notice to claimant (Section 9113). IV. P0ARD ORDER: By unani lous vote of the Supervisors present: (V,)"' This Claim is rejected in full. O Other: I I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated:DJOHN SWEETEN, CLERKtB , Deputy Clerk WARNING(Gov. code sectr n Subject to certain exceptions, you have only six (6)months from the dale this notice was personally served or deposit 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 I 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 full prepaid a certified copy of this Board Order and Notice to Claim att ssed to the claimant as shown above. Dated:Put7hie!'W JOHN SWEETEN, CLE Deputy Clel -LT_ b 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 1065 County Administration Building, 651 Pine Street,Martinez, CA 94553. C. If claim is against a district governed by the Board of Supeivisors, 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. o■•O Y Y■■!i p l!9 6 t I U■e e..a EVEN EVE N G e e s s t RE: Claim B`y: Reserved for Clerk's filing stamp �S$40 +- Sou IAO ) rin a/�, Against the County of Contra Costa or j /yUV Z 3 C(ERKB ZQQS District) COO ��ops (Fill in the name) I ) eoER STA Co��SORS The undersigned claimant hereby makes(claim against the County of Contra Costa or the above-named district in the sung of$ 7o.S // and in support of this claim represents as follows: 1. V✓ihen did the damage or injury occur? (Give exact date and hour) VOL/ /S, Zoo�- 063rd 2. Where did the damage or injury occur? (Include city and county) ��Ole_ (/Alley- AdppRog . V2_ m�l� mud 3. How did the damage or injury occur? -(Give full details; use extra paper if required) _.. . . -LoV.) -+P-Lr L IM h 4. What particular act or omission on the part of county or district officers, servants, or employees caused the injury or damage? 17A Ju►2e_ -+a L j �, I-le,g 1-ir 5 What are the names of county or district officers, servants, or employees causing the damage or injury? d 6. What damage or injuries do your claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto dama e.) _T ie. L� Mf) 73d208e- eC � Ai/L &/)DifiOnrerL ROW) 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) WA7Gf< f�eJACC mend ShRouD 8. Names and addresses of witnesses, doctors, and hospitals: 9. List the expenditures you made on account of this accident or injtuy: DATE TIME AMOUNT $h2pQI ff mausaaaoaea a•saesauM E sous o Masao so lffataana Mff ansa sus aassrM mffuff Mvffau Msaaaff n• ■affaaaaaff9 1 .Gov. Code Sec. 910.2 provides "The claim shall be signed the claimant or by some person on his b�eh SEND NOTICES TO: (Attorneyl 1 Name and address of Attorney ) ) i v (Claimant's Signa (Address) Telephone No. ) Telephone No. �� ■aa■•a■uaaso■a■■oova ssmaausv■aes■leaasseoeasa••anasac eMsaaaeasueeaaff aMa ea aM a a a a a a a a a9 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, 95 6500 et seq.) Furthermore, any attachments, addendums, or supplements attached ched to the claim form, including medical records, are also subject to public disclosure. ausaffunuumno sasaaaaM snuffs son MaMastsaaao■ astaetuskMEN 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 exceedung 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. 691565 CUSTOMER' ORDER NO. DATE NAME ADDRESS CITY,STATE,ZIP SOLD BY CA H C.O.D.CHARGE ON ACCT. IADSE I PAID OUT RETD. ti. DUAN. DESCRIPTION AMOUNT I +C�S`(oud \\�7J� 2 3 f r A 5 \ 6 7 i2 RECEIVED BY KEE P THIS SLIP FOR REFERENCE a,.... 3705 CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION: DEC. 20, 2005 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), give► Pursuant to Government Code Section 913 and NOV 2 S 2005 915.4. Please note all "Warnings". AMOUNT: $250,000 OOiNezcaSEL MARTCLAIMANT: JASON STENSON ATTORNEY: HARVEY M. KLETZ DATE RECEIVED: NOV. 23, 2005 ADDRESS: 5315 COLLEGE AVENUE BY DELIVERY TO CLERK ON: NOV. 23, 2005 OAKLAND, CA 94618 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 SW lerk Dated: NOVEMBER 23, 2005 . By: Deputy rI. MOM: County Counsel. TO: Clerk of the Board of Su rvison; �w.h'Any (4a,'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). (►�Clainhi #timely filed. n.grmind that ir • �� a ��� ��� ^d ^F i Other: See- JekpM �,�vcl►1 , a/ 'Ey'1-or )a- cl� r�,. VIDELL 6pu C c� q J7 3 �- 4,e 1.0��� i J de I pA ^r+ 04 I � o er✓c rt �� Co •,< dr,� o Dated: f/�'a�' I By: Deputy County Coun III. FROM: Clerk of the Board TOI County Counsel (1) County Administrator(2) O Claim was returned as untimely with notice to claimant (Section 911.3). IV. ARD ORDER: By unaniml us vote of the Supervisors present: (1'}�This Claim is rejected in full. O Other: �I I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. DatedAo bayJOHN SWEETEN, CLE e uty Clerk WARNING (Gov. code sect n 913) Subject to certain exceptions, you have only six (6) months from the d e this no a was personally served or deposit 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 I 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 full prepaid a certified copy of this Board Ori er and Notice to Claimant% ddres d to the claimant as shown above. Dated:Aa e�bo+�.a/ HN SWEETEN, CLERK11i Deputy Clet OFFICE OF THE COUNTY COUNSELSILVANO B.MARCHESI COUNTY OF CONTRA COSTAti+1�- —'_0�, COUNTY COUNSEL Administration Building SHARON L. ANDERSON 651 Pine Street, 91" Floor i - `.� ' -> -,- - ' Martinez, California 94553-1229 � :- _ ; CHIEF ASSISTANT ' GREGORY C.HARVEY (925) 335-1800 VALERIE J. RANCHE (925) 646-1078 (fax) �', - ad � '' k� AssIsTANTs �OSrA COUK December 2, 2005 Harvey M. Kletz 5315 College Avenue Oakland, CA 94618 Re: Government Tort Claim of Jason Stenson Dear Mr. Kletz: 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 of Supervisors 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 Monika L. Cooper Deputy County Counsel OFFICE OF THE COUNTY COUNSEL SILVANO B. MARCHESI COUNTY OF CONTRA COSTA -S-e- _p�, COUNTY COUNSEL Administration Building 651 Pine Street, 91h Floor a SHARON L. /ANDERSON Martinez, California 94553-1229 ';' _ o_ CHIEF ASSISTANT ' (925) 335-1800 GREGORY C. HARVEY nt -�..Tad11Y\\\\ VALERIE J. RANCHE�� � �� O (925) 646-1078 (fax) ; 5 kO ASSISTANTS OSrA COU>1� STATUTORY WARNING PURSUANT TO GOVERNMENT CODE SECTION 911.3 TO: Harvey M. Kletz 5315 College Avenue Oakland, CA 94618 RE: Claim of Jason Stenson Please Take Notice as Follows: The claim you presented to the Contra Costa County Board of Supervisors on November 23, 2005 was reviewed by County Counsel. The portion of the claim prior to May 23, 2005 was not presented within six months after the event or occurrence as required by law. Because you allege late discovery of the claim, the claim is "timely on its face" and will be reviewed and acted upon by the Bioard of Supervisors within the statutory time period. To preserve the rights of the County, its departments and employees to challenge the validity of your late discovery claim, you are warned pursuant to statute that if your delayed discovery argument is improper, your claim is late, and is being returned because it was not presented within six months after the event or occurrence as required by law. (See Gov. Code, §§ 901, 911.2.) Because the claim may not have been presented within the time allowed by law, we warn you that to preserve your right in the event your claim is determined to be late, your only recourse at this time is to apply without delay to the Contra Costa County Board of Supervisors for leave to present a late claim. (See Gov. Code, §§ 911.4 to 912.2, inclusive, and 946.6.) Under some circumstances, leave to present a late claim will be granted. (See Gov. Code, § 911.6.) Page 1 SILVANO B. MARCHER COUNTY COUNSEL By: Monika L. Cooper Deputy County Counsel CERTIFICATE OF SERVICE BY MAIL (Code Civ. Proci, §§ 1012, 1013a, 2015.5; Evid. Code, §§ 641, 664) 1 am a resident of the State of California, over the age of eighteen years, and not a party to the within action. My business address is Office of the County Counsel, 651 Pine Street, 9th Floor, Martinez, CA 94553-1229. On L-Vee&bA S, UV 5' I served a true copy of this Statutory Warning Pursuant to Government Code Section 911.3 by placing the document in a sealed envelope with postage thereon fully prepaid, in the United States mail at Martinez, California addressed to Harvey M. Kletz, 5315 College Avenue, Oakland, CA 94618, as set forth above. I am readily familiar with Office of County Counsel's practice of collection and processing of correspondence for mailing. Under that practice, it would be deposited with the U.S. Postal Service on that same day with postage thereon fully prepaid in the ordinary course of business. I declare under penalty of perjury under the laws of the State of California and the United States of America that the above is true and correct. Executed on` �isB/yc%r 2,m5 /r, at Martinez, California. Kathleen O'Connell cc: Clerk of the Board of Supervisors(original) Risk Management Page 2 tli/�011/2005 13:59 CONTRA COSTA COUNTY CLERK OF THE � 915106553954 NO.491 901 BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT A. A claim relating to a cause of actilon 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.) I B. Claims must be filed with file Clerk of the Hoard of Supervisors at its office in Room 106, County Administration Building,1651 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. I E. Fraud, See penalty for fraudulent claims, Penal Code Sec. 72 at the end of this form. ••@DOWN*DoIu"roa%■.ss"11*%somas somusoaasea as%@*Igo @amhDaadNow Gov onamps aa%agoI l RE: Claim By: Reserved for Clerk's filing stamp 1` 1 JASON ST�,FNSnN j RECEIVE® I Against the County of Contra Costa or ) NOV 2 3 aj District) CLERK BOARD OF (Fill in the name) I ) CONTRA COV: ) The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named district in the sum of$2 5 0 , 0 0 0 I and in support of this elaun represents as follows: 1. When did the damage or injury occur? (Give exact date and hour) The negligence occurred on September 23 , 1997 but wqs not discovered until October 25 , 2005 . 2. Where did the damage or injury occur? (Include city and coutity) Martinez and other cities within Contra Costa County. 3, How did the damage or injury occur? (Give full details; use extra paper if required) SEE ATTACHED 4. What particular act or omission on the part of county or district officers, servants, or employees caused the injury ordamage? SEE RESPONSE TO N0. 3 5 What are the names of county or district officers,servants, or employees causing the damage or injury? Contra Costa County Clerk 11/01/2005 . 13:59 CONTRA COSTA COUNTY CLERK OF THE 4 915106553954 • N0.491 D02 /^ I 6. What damage or injuries do your claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for,auto damage.) Loss of income in th e amount of $250, 000 plus emotional distress 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) Details and eact amount are still being calculated 8. Names and addresses of witnesses,doctors, and hospitals: Not applicable I 9. list the expenditures you made on account of this accident or injury: DATE TINE AMOUNT Unknown at this time I ..............anaaoa...■..■sees■■.■■■■..■...■raRoom*■.■aa■■■....■..■...■..■■.■.■■.■&$ �) Gov. Code Sec. 910.2 provide "The claim shall be signed by the claimant or by so a person on his behal ." SEND NOTICES TO: (Attomey) ) Name and address of Attorney ) HARVEY M. KLETZ (Cl.ailnarit's Si tore) ATTORNEY AT LAW ) HARVEY M. KL ) A1'fORNEY AT 5315 COLLEGE AVENUE OAKLAND, CA 94618 �3',T6A1 1 €raF�AV�UE OAKLAN��'e�t8 ., } } Telephone No. ( 510 ) 699-7141 )Telephone No. •.■r■..r■.■■■■..■.■■..■■.■.■r■■L■r■r■■■■■r■■r■r■r■.■■■r■■■.r■■.■■■ossesa■■■■r.■■■■r■l 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 tinder the California Public Records Act, (Gov. Code, §6 6500 et seq.) Furthermore, any attachments,addendums, or supplements attached to the claire form, including medical records, are also subject to public disclosure. as%besell son*soup*museumssmm■sal■■sm■■a■■■■seas s■ssssr.malso■..■.■...■■■■.■...■.■ ■■■$ 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 counry, 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 al fine of not exceeding one thousand dollars ($1,000,00), or by both such imprisonment and fine, or by imprison Snent in the state prison, by a fine of not exceeding ten thousand dollars ($10,000), or by both such imprisonment and fine. 3. On September 23, 1997, Jason Stenson, Sr.,plead guilty to a misdemeanor Health and Safety Code Section 11350M violation. At that time, the Clerk of the Court incorrectly entered the plea as a felony. Subsequent to September 23, 1997, Mr. Stenson has been unable to receive numerous jobs as a result of employer's determining that he, in fact, had a felony conviction which was erroneous. LAW OFFICE'S OF HARVEY M. KLETZ EMAIL: 5319 COI.LEGIi AVENUE TEL(510)655-7141 hkletz@aol.cotn OAKLAND,CALIFORNIA 94618 FAX(510)655-3954 November 22, 2005 REC E TRANSMITTAL MEMO NOV 2 3 NOD s.,PERViSORS TO: Clerk CLERK UiATRA� i',co. Contra Costa County Board of Supervisors 651 Pine Street, Room 106 Martinez, CA 94553 SUBJECT: STEIVS6N'v. C01W RA COSTA CL LINTY ENCLOSURES: ORIGINAL AND ONE (1) COPY OF CLAIM REQUESTED ACTION: ( I Enclosed for your information. [ ] Please telephone me after reviewing the enclosed.. [X] Please file original(s) and return endorsed [ ] Please telephone my office and make an copies. appointment. [ ] Enclosed is a check for fees. [ ] Please have the Judge sign. [ ] Please record original and return copies. [ ] Enclosed is a check. [ ] Instructions/Remarks: Thank you. Sincerely yours, Denise Taylor Assistant to HARVEY M. KLETZ enclosures - w 2 � t - � - : . § x 2@@2 QQ � . . ..� / � m ! % } / CD LAJ> � . . * � lei q �/ # 3<, c"D « >/o L G LA- � a / OLAJ 102 V) U W u. U �} ± O . 0 U \ . # Ln ® Ln O» . CLAIM 67 BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION: DEC. 20, 2005 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 !!ll 29�Qifl�lf-�a�� D Board of Supervisors. (Paragraph IV below), giver Pursuant to Government Code Section 913 and NOV 2 3 2005 915.4. Please note all "Warnings". (Vif INITv nn'1—If AMOUNT: AMOUNT11KILTI�N;THE JURISDICTION OF SUPERIOR COURT CLAIMANT: DANTE AND EVELYN ALCANTARA ATTORNEY: ROBERT A.7 MILLER DATE RECEIVED: NOV. 232 2005 ADDRESS. STERNBERG & COAD-HERMI..IN BY DELIVERY TO CLERK ON: NOV. 23, 2005 540 LENNON LANE WALNUT CREEK, CA 94598 BY MAIL POSTMARKED: NOV. 229 2005 FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN SWEET N C rk Dated: NOVEMBER 23, 2005 By: Deputy II. FkOM: County Counsel . TO: Clerk of the Board of Superv'sors ( ltis claim complies substantially with Sections 910 and 910.2. ( ) This Claim FAILS to comply substanItially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Sectio 910.8). O 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: I By: � "�''� Deputy County Coum III. FROM: Clerk of the Board TOI 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: (tfThis Claim is rejected in full. ( ) Other: I I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: ,rc�iJ OHN SWEETEN, CL , De -uly Clerk WARNING (Gov. code secti 913) Subject to certain exceptions, you have inly six (6)months from the date this no ce was personally served or deposit 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 comrection wiih 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 I 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 full prepaid a certified copy of this Board Ori er and Notice to Claintartt addressed to the claimant as shown above. q dUHN SWEETEN CLERK y 1 e uty Clel Dated: .eG�,v- -har7✓ ?/ , RECEIVED STERNBERG & COAD-BERMELIN LLP NOV 2 3 2005 ATTORNEYS AT LAW CLERK BOARD D;•s;.;s,_RRESOR8 540 Lennon Lane CONTRA Cu, i;.Co. Walnut Creek,CA 94598 (925)946-1400 Facsimile(925)932-6986 November 23, 2005 Clerk of the Board of Supervisors 651 Pine St. Martinez, CA Re: Dante & Evelyn Alcantara Property located at 127 Harris Circle, Bay Point, CA 94565 To Whom It May Concern: This letter is submitted as a Claim under Government Code §900 et seq. Per discussion with James Kennedy, Redevelopment Director, the Alcantaras were directed to submit a claim in a letter to the Clerk of the Board o i Supervisors. On November 9, 1994 Dante and Evelyn Alcantara entered into an agreement with the Contra Costa County Redevelopment Agency through which the Agency loaned Twenty Five Thousand Two Hundred Dollars ($25,250) to Mr. and Mrs. Alcantara. After approximately 10 years, the Alcantaras decided to sell their home. In compliance with the Resale Restriction Agreement, the Alcantara's noticed the Agency ofitheir intent to sell their property, and the Agency exercised its option to purchase. An eligible purchaser then assumed the full amount due, which included interest at the close of escrow on ay 27, 2005 as a new loan in the amount of Fifty Thousand Four Hundred Eighty Dollars ($50M,480). Contrary to the Resale Restriction Agreement, the Agency failed to provide to the Alcantaras the fair market value pursuant to the Agreement's Restricted Resale Price section titled Selling Your Home After 10 Years. Furthermore,the Agency failed to forgive or cancel repayment of the $50,480 (initial $25,000 loan pluslinterest) once the new eligible purchaser assumed the loan pursuant to the Agreement's Eligible Purchaser section titled Sale To An Eligible Purchaser. The names of the public employee causing the Alcantara's injuries are James Kennedy- Deputy Director- Redevelopment; Dennis M. Barry, AICP, Community Development Director; Sara Welch and Linda Hoover Baty. �t Clerk of the Board of Supervisors November 23, 2005 Page 2 The Alcantaras' claim as of this date is in an amount that would place it within the unlimited jurisdiction of the Superior Court. The claim is based on the injury, damage, and/or loss in the amount specified above. All notices should be sent to my office at the above address. Sincerely, STERNBERG & COAD-HERMELIN, LLP ROBERT A. MILLER RAM:dfh cc: Dante and Evelyn Alcantara CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY �• �j BOARD ACTION: DEC: 20, 2005 Claim Against the County, or District Governed by ) the Board,of Super Visors,Routing-Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Se ctionreferences are to ) The copy of this document mailed to you is your California Governrrieiit Codes. ) notice of the action taken on your claim by the ` iVOV 2 ?005 C Board of Supervisors. (Paragraph IV below), gives COU" Tyrr,f ;- - Pursuant to Government Code Section 913 and Ar'�;�7f;J�L -lr'- ` ' 915.4. Please note all "Warnings". AMOUNT: UNLIMITED CIVIL CLAIMANT: JAMES W. BEAU, JR. . ATTORNEY: PETER W. MANION DATE RECEIVED: NOV. 28, 2005 ADDRESS: HAKEEM, ELLIS & MARENGO BY DELIVERY TO CLERK ON:NOV. 285 2005 3414 BROOKSIDE ROAD, #100 STOCKTON, CA 95219 NOV. 201 2005 BY MAIL POSTMARKED: FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. NOVEMBER 2$ 2005 .. L JOHN SWEET 1 Dated: By: Deputy II. FkOM: County Counsel. TO:(Clerk of the Board of Supervi rs ( "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). O 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). O Other: 1 Dated: Z' �`� I By: ryl �%A,-- Deputy County Coun; III. FROM: Clerk of the Board TO I County Counsel (1) County Administrator(2) O Claim was returned as untimely with notice to claimant (Section 911.3). IV. ORDER: By unanimous vote of the Supervisors present: ( This Claim is rejected in full ( ) Other: I I certify that this is a true and co lect copy of the Board's Order entere ' its minutes for this date. c> DatedQOHN SWEETEN, CLERK, y , Deputy Clerk WARNING (Gov. code secti 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposit 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 full prepaid a certified copy of this Board Order and Notice to Claimant, ad to the claimant as shown above. Dated:0 ,,,6c�' OHN S,EETEN, CLERK y Deputy Clet 11/22/2005 16:00 CONTRA COSTA COUNTY CLERK OF THE 4 912094743654 NO.554 1?01 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 atter 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. B. 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 James W. Beall, Jr. RECEIVED Against the County of Contra Costa or ) NOV 2 8 L003" District) CLERK BOARD OF SLIPERVISORS (Pill in the name) ) CONTRA COSYA CO. } The undersigned. claimanrlberebb mals claim against the County of Contra Costa or the above-named un unit d district i11 the stem of$ civil and in support of this claim represents as follows: I. When did the damage or injury occur? (Give exact date and hour) May 24, 2005 at approximately 3:25 p.m. 2. Where did the damage or injwy occur? (Include city and county) Marsh Creek Road at intersection with-Camino Diablo in unincorporated Contra Costa County, California 3. How did the damage or injury occur.) (Give full details; use extra paper if required) The motorcycle on which claimant was riding collided with a trailer that was being pulled by a Peterbilt tractor. 4. What particular act or omission on the part of county or district officers, servants, or employees caused the injury or damage? See Attachment A 5 What are the names of county or district officers, servants, or employees causing the damage or injury? Unknown 11/22/GbbS 16:00 CONTRA COSTA COUNTY CLERK OF THE 4 912094743654 NO.554 P02 6. What damage or injuries do your claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage.) So far as is presently known, injuries to both legs, the right hip, both arms, head trauma, including brain damage, pain and suffering, past and future medical bills, disfigurement, permanent disability, loss of enjoyment of life, lost past and futurwages, d diminish 4 e.a n ng capacity 7. flow was tete amount caimeclr move computed? (Include the estimated amount of any prospective injury or damage.) Not required pursuant to Government Code Section 910. 8. Names and addresses of witnesses, doctors, and hospitals: Not required pursuant to Government Code Section 910. 9. List the expenditures you made on account of this accident or injury: DATE TIME AMOUNT Not required pursuant to Government Code Section 910. ■■r■rrr■■rrrrrrrr■•••■■•s.■■.■rrrrrrrr■rrrrrrrrrrrr■■rrrrrrrrrrrr■rr■r■rr•■■■..■■rrr, 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 Peter W, Manion, Esq. Hakeem, Ellis & Marengo ) (Claimant's Signature) By Attorney 3414 Brookside Road, #100 ) . Stockton, CA 95219 Claimant: 1888 Mustang Court (Address) Concord, CA 94521 (925) 689-3976 Telephone No. (209) 474-2800 )Telephone No. ■■■■rr.r■■■■■■..r.■■■■r■■■rrr.■rrrrrrrrr■a 9 0 r r r r r r r r r r r r r r r r r r r r r r g r r a r..r■.■r■■, 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,addend=s,or supplements attached to the claim form, including medical records, are also subject to public disclosure. r u rrrrrrrrrrrrrrr■rrrrr■■rrrrrrrrrrr•••■rr�rrrrrrrrrrrrrrrrrr■rrrrr•■rr�rrrrr■�■..■ 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. ATTACHMENT A The design and/or construction of the roadways in the area of the intersection where the accident occurred constituted an unreasonably dangerous condition for motorists, such as claimant, who are traveling on said roadways with due care. Moreover, this dangerous condition, which is likely to cause collisions between vehicles, is not reasonably apparent to a person exercising due care and, therefore, the public entity was negligent by -failing to post traffic and/or warning signals, signs, markings, and/or devices to warn motorists of the dangerous condition and to warn of the need to decrease speed. Said failure constitutes a dangerous trap to motorists in the area, because it is not apparent to motorists continuing northbound on Marsh Creek Road, who have the right-of-way, that motorists traveling southbound on Marsh Creek Road may be making a left turn directly in violation of the northbound motorists' right-of-way. This dangerous condition creates the probability for accidents and resulted in the accident giving rise to this claim. The public entity has had actual or constructive notice of this dangerous condition and has had further actual or constructive notice that the aforementioned design is no longer in conformity with a plan or design or a standard that reasonably could be approved, and has existed in that state for sufficient time for the public entity to have remedied the condition. , 1 PROOF OF SERVICE [C.C.P. 1013(a)] 2 STATE OF CALIFORNIA } 3 }ss. COUNTY OF SAN JOAQUIN } 4 I, Colleen Davis, declare that I am over the age of eighteen and not a party to this action. My 5 business address is Hakeem, Ellis& Marengo, 3414 Brookside Road, Suite#100, Stockton, California 95219, which is located in the County of San Joaquin where the service described below took place. 6 On the date below, at my place of business at Stockton, California, a copy of the following 7 document(s): 8 BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT AND CLAIM FORM 9 was placed in a sealed envelope addressed to: 10 Clerk of the Board of Supervisors 11 Room 106 County Administration Building 12 651 Pine Street Martinez, CA 94553 13 [x] BY U.S. MAIL: I placed the above documents in a sealed envelope for deposit in the United 14 States Postal Service, with first class postage fully prepaid, and that envelope was placed for collection and mailing on that date following ordinary business practices as indicated above. 15 [] BY FACSIMILE TRANSMISSION: I transmitted the above documents by facsimile 16 transmission to the FAX telephone number listed for each party above and obtained confirmation of complete transmittal thereof. 17 [] BY CAUSING PERSONAL SERVICE: I placed the above documents in a sealed envelope. I 18 caused such envelope(i)to be handed to our messenger service to be delivered as indicated above. 19 [] BY OVERNIGHT EXPRESS: I placed the above documents in a sealed envelope. I caused such 20 envelope(s) to be delivered by Federal Express to the above address(es)by overnight express. 21 I am readily familiar with the business practice at my place of business for collection and processing of correspondence for mailing with the United States Postal Service. On the same day that 1 22 place a sealed envelope in the internal mail system of Hakeem, Ellis & Marengo for collection and mailing, it is deposited in the ordinary course of business with the United States Postal Service with first 23 class postage fully prepaid. 24 1 declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Executed on November 23, 2005, at Stockton, California. 25 26 Colleen Davis 27 28 �Ckt v Y� w � +t i r i Y cn `. vp � C%r::i p or, Z r. If" r� 1 o o N LtC o W w Vl �Y 2w W W M t r. CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION: DEC. 20, 2005 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'Cbdes. ) notice of the action taken on your claim by the R Board of Supervisors. (Paragraph IV below), give► 0'J 2 2GG5 Pursuant to Government Code Section 913 and CF',!TY(,,.,, �_, : 915.4. Please note all "Warnings". AMOUNT: $107000.00 CLAIMANT: LAMOS W. STURGIS #2005018962 Q=MODULE #5 ATTORNEY: j NK!ora�TT A'1'1 RPTEY DATE RECEIVED: NOV. 287 2005 ADDRESS: -- ' 3OX 5A) BY DELIVERY TO CLERK ON: NOV. 28, 2005 --MAIN DETENTION FACILITY BY MAIL POSTMARKED: NOV. 24, 2005 1000 WARD STREET, FROM: Clerk of io u ors TO: County Counsel Attached is a copy of the above- noted claim. JOHN SWEE N, erk Dated: NOVEMBER 28, 2005 . By: Deputy II. FkOM: County Counsel. TO:(Clerk of the Board of Supe 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). O 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). t. ( ') Other: f Dated: 12" J I By: Deputy County Coun; 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: (l This Claim is rejected in full. ( ) Other: I I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. DatedA ftP.VV,6 Wil OHN SWEETEN, CLERk , PA3,bty Clerk WARNING (Gov. code sectio 913 Subject to certain exceptions, you have only six (6) months from the date this n is was personally served or deposit 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 I now, and at all tithes herein nientioned, 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 full prepaid a certified copy of this Board Order and Notice to Claimant ress to the claimant as shown above. Dated:Pe f xP -ee W/416) S I EETEN, CLERK Deputy Cle► Claim to: BOARD,OF SUPERVISORC OF CONTRA COSTA COUNTY INSTRUCTIONS TO'CLAIMANT A. Claims relating to causes of action for death or for injury to person or to personal property or growing crops and which accrue on or before December 31, 1987, must be presented not later than the 100 day after the accrual of the cause of action. Claims relating to causes of action for death or for injury to person or to personal property or Stowing crops and which accrue on or after January 1, 1988, must be presented not later than six month's 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. (Gov't Code 911.2.) r` 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. s 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 jRECEIVED Against the County of Contra Costa or ) NOV 2 8 1005 /°,o,✓ RA- I'DST, , hT_'AA District) CLERK BOARD O St,?ER!!I£ORS (Fill in name) ) CONTRA COST;CO. The undersigned claimant hereby makes(claim against the County of Contra Costa or the above-named district in the sum of$/D-0,W-`" and in support of this claim represents as follows: 1. When did the damage orinjury occur? (Give exact date and hour) 1~3,05a� 0J�/a/'oxokc17m //--00 A#I 2. Where did the damage or injury occur? (Include city and county) AA;14 7�rTENTioN > e;/;>, Q �vodu/e 901 COv,0— sT v`7A1?;i'N0Z. 3. How did the damage or injury occur? (Give full details; use extra paper if required) 1 4: What particular act or omission on the part of cowity or district officers, servants, or employees caused the injury or damage? ��A,yp Cu PSE A,vT S�.aRrc z� 7/�7; R ixl &/9c 1i+l �N6 V/ ir ;VrAT7, 7z�ONT, ,Page et nc/ VepuiY 5. What are the names of ouitty or district officers, servants, or em ' ���ihe damage or injury? p gees causing g j ry. 27��NT� cQosc Vr'P j� vlc��sLarC 6. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage.) / L C.` t,f 7. How was the amount claimed above computed? /Iudue�tKmde emoth o y prospective injury or damage.) pe 9s pse" � / I ion 8. Names and addresses of witnesses, doctors, and hospitals. / !Nk A1407' SF,6^1 44771,"z a i,.�P% r AT' '� X A// 4AIs ,.A/ 4-dy�� f lkJ �✓:y rs .-�� �1 9. List the expenditures you made on account of this accident or injury. DATE TIME AMOUNT ****************************************************************************************** ) Gov. Code Sec. 910.2 provides "The claim must be ) signed by the claimant or by some person on his behalf." SEND NOTICES TO: (Attorney Name and Address of Attorney ) /4 0=,a A �- (Claimant's Sig ture) (Address) .0000) Telephone No. )Telephone No. NOTICE Section 72 of the Penal Code provides: Every person who,with intent to defraud,presents for allowance or the 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(S 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(S 10,000),or by both such imprisonment and fine. 0 l 7 LAUlM tA .o 9 O .. ` 2-, i Q i LU LUL C, a dA • ,0 p �t d"