HomeMy WebLinkAboutMINUTES - 01162007 - C.5 (16) CLAIM
BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY
BOARD ACTION: JANUARY 16, 2007
Claim Against the County, or District Govemed 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
California Government Codes. ) you is your notice of the action taken
on your claim by the Board of
D Supervisors. (Paragraph IV below),
given Pursuant to Government Code
AMOUNT: $1 , 553. 25 DEC 1 Section 913 and 915. 4. Please note all
1 2006 "Warnings".
CLAIMANT: JOHN KIKES COUNTY COUNSEL
MARTINEZ CALIF.
ATTORNEY: UNKNOWN DATE RECEIVED: DECEMBER 11 , 2006
ADDRESS: 611 EXETER PLACE BY DELIVERY TO CLERK ON: DECEMBER 11, 2006
DANVILLE, CA 94506
BY MAIL POSTMARKED: DECEMBER 10, 2006
FROM: Clerk of the Board of Supervisors TO: County Counsel
Attached is a copy of the above-noted claim.
JOHN CULLEN, r
Dated: DECEMBER 11 , 2006 By: Deputy
11. FROM: County Counsel TO: Clerk of the Board of Su rvis 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).
( ) 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: z,2— ro By: Deputy County Counsel
111. FROM: Clerk of the Board TO: County Counsel (1) County Administrator(2)
O 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.
O Other:
I cetlify that this is a true and correct copy of the Board's Order entered in its minutes for
this date.
Dated: A/T�w4✓ �dp HNCULLEN, CLERK, By Deputy Clerk
WARNING (Go . code section 913)
Subject to certain exceptions,you have only six(6) ntontlis fironn the date this notice was personally seined
or deposited in the nuail to file a court action on this claim.See Government Code Section 945.6.Vou may
seek the advice of•an attorney of your choice in connection with this matter. If you want to consult an
attorney,),ou should do so innmetliately. *For Additional Warnhi ;See Reverse Side ofThis 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 Nlartinez, California, postage fully prepaid a certified copy of this
Board Order and Notice to Claimant, addressed to the claimant as shown above.
Dated: 1ar2 Y /1fi �� JOHN CULLEN, CLERK By Deputy Clerk
J . .
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 Cleric 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 fi audulent claims,Penal Code Sec. 72 at the end of this form.
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RE: Claim By: Reserved for Clerk's filing stamp
_'SelnhK�I��S RECEDED
So ) EC 1 1 2006
D
Against the County of Contra Costa or )
CLERK BOARD OF SUPERVISORS
District)
CON rRA 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)
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2. Where did the damage or injury occur? (Include city and county) -�k v- —b
3. How did the damage or injury occur? (Give full detailstl e required
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4. What particular act or omission on the part of county or district officers, servants, or employees
caused the injury or damage? 0 &v�
5 What are the names of county or district officers, servants, or employees causing the
damage or injury? yvv-YP
1 . .
6. What damage or injuries do your claim resulted? (Give full extent of injuries �damages
claimed. Attach two estimates for auto damage.) .
1. How was th`" e 'dmoun c10-aA4-1- - OA�
laimed above computed? (Inc ude the estivaiated amount of any
prospectiveinjuryor damage.)
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
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.Gov. Code Sec. 910.2 provides "The claim shall be
signed by the claimant or by some person on his
behalf."
SEND NOTICES TO: (Attomev)
Name and address of Attorney )
(Claimant's Signature)
(Address)
Telephone No. )Telephone No.
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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.
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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 couni�y, 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
the state prison, by a fine of not exceeding ten thousand dollars
imprisonment and fine, or by imprisonment in
($10,000), or by both such imprisonment and fine.
SPECoAS CONDITION5HIT 8 RUN CITU .. 1
144
,� COUNIY REPORTING DISTWCi DEAT REPORTING 10FRCER
LALaG, O.O. DAY YEAA T1ME(2400) NGC L�'7 FFICER 1.D.
COLLISION OCCUR DON i�✓r �) ��/ I, • DO C /`
DAY OF WEEK TOW AWAY STATE WOHN'AY R L TED
A INTTERSECTIOH WITH S M T W T F S ❑YES NO ❑YES
OR: FE ETI MILES OF
STATE I CLAS6 SAFETY EQUIP. SHADE SKETCH �
PARTY DRIVE fl'8 LIGQN6,E NUMBER �4,k L C Pf C_ DAMAO ED �1 C
1G_ PHONE NUMBER AREADRIVER NAME IFTRQ D LL y_S C�w-5 � COsO 14ORTND4CA
i�i ! NORTI
PED. 9TflEE7 ADDREHB�m LQ
PK VEH gT-PAYEL
Bn
�. I INSURANCE (' � �POLI1.O Y/NUM BwER arm I �f
`1y SPEED ULT. •J
BICYCLE OR HIGHWAY too-
�`1
1
OTHER KE/MODELICOLOP LICENSE NUMBER STATE VEH.TYPE PARTY
mecQI
STATE CLAS6 SAFETY EOUP, SHADE I
PARTY DFUVER'S LICENSE NUMBER DAMAGED /
AREA
2 PHONE NUMBER ,
DRIVER NAME(FIRST,MIDDLE,LAST) r CITYISTATEIZIP
PED. STREET ADDRESSPKVEH SEX BIRTHDATE NSURANCE CARRIER POLICY.NUMBER
.(CYCLE DIR.TRAY EL20
N STREET OR HIGHWAYLICENSE NUMBER STATE VEKTYPEPA2TY
OTHER VEH.YR MAKE/MODEL I COLOR
ADDRESS
PHONE NUMBER PARTY NO
WR. RIO AGE HEX NAME
❑ ❑ PHONE NUMBER PARTY NO
ADDRESS
75-E HEX NAME
❑ ❑ DAMAGED PROPERTY
ADDRESS
PROP. NAME
OWNER
IMPORTANT — READ CAREFULLY
Keep this report, This is your record of this accident. To comply with California Vehicle Code (VC) Section
20002 (duty where property damaged), you must either:
a. Give the owner or person in charge of such property the name and address of the driver and owner of the
vehicle, or in the absence of the owner,
b. Leave a written notice in a conspicuous place on the other vehicle or damaged property, giving the name
and address of the driver and owner of the vehicle involved and a statement of the circumstances.
This information is necessary for the completion of your state SR-1 Form, Report of Traffic Accident, and your
insurance report.
VEHICLE CODE SECTION 16000
The driver of a vehicle involved in an accident resulting in damage to the property of any ONE party in excess
of the amount stated in VC Section 16000 or in the injury or death of any person MUST submit a SR-1 Form to
the California Department of Motor Vehicles within 10 days.
Note: Failure to comply may result in suspension of your driver's license,
Form SR-1 may be obtained from the Department of Motor Vehicles, the California Highway Patrol, any police
station, motor vehicle club, or insurance agent.
If city or state property is damaged, you will be contacted regarding possible liability.
CAIJFORNIA HIGH\AdAY PATROL
499'9 GLEASON DRIVE
DUBLIN, CA 94568
CRP 555-09(REV11-88)OPI 042
DUBLIN, CALJl - 94--)ou
(925) 828-0166
Counter Report Questionnaire (Form should be attached to a CET 555-03,COun-ter Report
Face Pale)
This repori is for YOUR RECORD Oatrolh1Hitocument and Ru follow-up low riot rip h'il] otnly be or
substantiated by the California Highway
conducted if driver and vehicle can be sufficiently identified.
Revie-N and answer all a-onlicable ouestions, Please Print le�ib]v .
1. Date of Collision: Day of Week:
2. Time of Collision: A Pl
Time of Repor
3. Today's Date: ham'—la
t: 7 oo " •`30
^. In what County were you? aw.�
j, tiVhat City were you near? Ql�a.0-au��
6. On what Highway /Street were you driving?
7. In what direction were you heading?
8. u hat was the nearest Exit or Street?
9. What were the n-afnc conditions?
10. In what number lane were you d''-' -? (Le:� to rigil't5 1 i�e f lane n.�.
11. How fast were you traveling?
12. What was the Highway/ Stree:speed limit? 5
�..�. a h .
13. In what number lane was the other vehicle? tcx
1-'.. How fast was the other vehicle traveling? h\
15. If you were behind the other vehicle, ho«.- far? n \
16. Did the weather contribute to the collision? YN
If ves, explain:
17. What were you doing prior to the collision? (For exarnp]e: Looking to the ]ef, ,=nR��
lanes: looking at a map: tuning the radio: talking on the car phone: etc.) -�
18. Describe the events that lead up to the collision; including the actions that caused the
Collision- Be specific, include as muc�de zil as possible.v
r� o av,%_ n
` .
Continue61 ext Page
Counter Repor L (continued)
c vvk
19. What occurred after collision? Include actions and statements. O1VVV\
6-n `�•L
Comnlete questions 20-27 only if this was a hit and run collision. Otherwise, go to question 28.
20. Did it appear that the other driver was intentionally trying to leave the scene?
If yes.explain
21. Did you speal:with the other driver?
22. If so, what was said?
23. Was there a lanuuage barrier?
24. If not, did you attempt to stop the drive: or get his/her attention?
2�. Is it possible the other driver was unaware of the collision? (Pulling up along side of their
vchicle and waving your hands does not necessarily mean that the: lmow• who you are.
Additionally; a vehicle's size and the type of collision should alsobeconsidered)
26. Describe the other driver: Sex: Race: Weight: Height:-
Approx.Age: Hair Color: Length of Hair:
Facial Features: Tattoos: Scars:
27. If necessary, could you positively identify the other driver from a photograph?
28. Describe the other vehicle (Year. make model, color, license plate)
-7,�a`� _ S L S J -
Continued Next Page
CALIFORI+IA HIGHWAY PATROL - DUBLIN AREA
Counter Report(continued)
29. Desc ibe damage (if any) sustainee to the other vehicle: Paint uansfer Yes NO
Location of Dzr2ge:
Color;
Extent of carnage:
30. Describe;in detail, damage sustained to your vehicle: Paint Transfer: Yes o
Color of paint transfer: E xtent'of damage:
Location of damage:
31. List any passengers in your vehicle at the time of the collision:
Name:
Address:
Date of Birth:
Phone number:
Name:
Address: _
Date of Birth:
Phone Number:
Name:
Address:
Date of Birth:
Phone Number:
Name:
Address:
Date of Birth:
Phone Number:
Continued Next Page
CALIFORNIA HIGHNVAY PATROL - DUBLIN AKLc `,
Counter Report (continued)
32. Did you zttempt to contact the Caiiforaia Highw2v Patrol, or other law enforce-nen-, agency,
to rport the accident?
If so. did you speak with an ff)cer?
If there hzs beer a lapse of over one day�ncthe date of the collisio , please eMai: w=nat
delaved your reporting this collision:
1La - 1- - -
-nature:
Date N i
Si
Print Name:
Telephone Number: Hone: ��j 2Dg sb Work:
For Office Use Only'
Courtesy report, 4rea: Date fonvarded:
Report prepared by: ID "
s.� T.RES NO REFUNDS ON DEPOSITS
OR SPECIAL ORDERS
NATIONAL CUSTOMER SERVICE
PHONE #800 321-2446
CUSTOMER MUST PRESENT COPY
OF INVOICE FOR ANY WARRANTY
F2006
F SUPERVIStRS
OSTA CO.
AIR PRESSURE
LF RF
LR RR
r'o
SPA
1 GRANT BIG O TIRES PERMISSION TO OPERATE THE VEHICLE HEREIN DESCRIBED FOR THE PURPOSE Of TESTING, I UNDERSTAND I WILL NOT RECEIVE
TORQUE LBS.
INSPECTING.INCLUDES REMOVAL OF WHEELS AND DRUMS FOR THE PURPOSE OF INSPECTING THE BRAKES,SERVICING MY OLD PARTS UNLESS CHECKED FRONT
OR DELIVERY,I RELEASE BIG O TIRES FROM RESPONSIBILITY FOP LOSS O DAMAGE TO VEHICLE OR CONTENTS BELOW.
THEREIN,IN CASE OF FIRE,THEFT OR OTHER CAUSE BEYOND BIG O TIRE$ O -ROL.I AUTHORIZE THE REPAIR AND .,
/ SERVICE WORK LISTED ON THIS INVOICE TO BE PERFORMED FOR THE OUNT SH N BELOW.THERE WILL BE A
$10.00 PER DAY STORAGE CHARGE FOR ANY VEHICLE LEFT OVER 4}�1 OURS STIMATE RIVED BY VISUAL ❑YES,PLEASE RETURN MY REAR
INSPECTIONS WILL BE CONFIRMED BEFORE SERVICE IS PERFORMED. �y / OLD PARTS. -
%u'f .t 1• B/W
AMOUNT SIGNATURE I , .
TIRES WHEELS BRAKES SHOCKS STRUTS ALIGNMENT ITEM#34559(REV 3/06)
B.� TARES NO REFUNDS ON DEPOSITS
OR SPECIAL ORDERS
NATIONAL CUSTOMER SERVICE
PHONE#800 321-2446
CUSTOMER MUST PRESENT COPY
OF INVOICE FOR ANY WARRANTY
AIR PRESSURE
LF RF
LR RR
SPA
I GRANT BIG O TIRES PERMISSION TO OPERATE THE VEHICLE HEREIN DESCRIBED FOR THE PURPOSE OF TESTING, I UNDERSTAND I WILL NOT RECEIVE TORQUE LBS.
INSPECTING,INCLUDES REMOVAL OF WHEELS AND DRUMS FOR THE PURPOSE OF INSPECTING THE BRAKES,SERVICING MY OLD PARTS UNLESS CHECKED FRONT
OR DELIVERY.I RELEASE BIG O TIRES FROM RESPONSIBILITY FOR LOSS OR DAMAGE TO VEHICLE OR CONTENTS BELOW.
THEREIN,IN CASE OF FIRE,THEFT OR OTHER CAUSE BEYOND BIG O TIRES CONTROL.I AUTHORIZE THE REPAIR AND
0 SERVICE WORK LISTED ON THIS INVOICE TO BE PERFORMED FOR THE AMOUNT SHOWN BELOW.THERE WILL BEA
$10.00 PER DAY STORAGE CHARGE FOR ANY VEHICLE LEFT OVER 48 HOURS. ESTIMATES DERIVED BY VISUAL ❑VES,PLEASE RETURN MV REAR
INSPECTIONS WILL BE CONFIRMED BEFORE SERVICE IS PERFORMED. OLD PARTS. `n,w nAI
AMOUNT SIGNATURE
TIRES WHEELS BRAKES SHOCKS STRUTS ALIGNMENT ITEM#34559(REV 3/06)
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