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Rt r trt N{O < m m aTmm i mr i Zi S r Cq -; �zom $z� 7Dr�'C)D Mm TDA n A A m j Z p n U KTP N . OY p V r �Z m O N s O O 30 4 X Z D D ::- i X r in rn.; Z i 1 c mm Col-1 CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT Ap r i 1 21, 1987 and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to GoveC6UhocC:0Unsel Amount: $200, 000 . 00 Section 913 and 915.4. Please note all "Warnings". CLAIMANT: INDUSTRIAL INDEMNITY COMPANY MAR`2 6 1987 c/o Leon A. Brunet, Ramos , Herlihy, Broadbeck, Hepler VgR4�e ATTORNEY: 101 California St. #1870 ' CA 045 San Francisco, CA 94111 Date received ADDRESS: BY DELIVERY TO CLERK ON March 20, 1987 hand del . BY MAIL POSTMARKED: no postmark I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. March 20 1987 PpHHIL BATCHELOR, Clerk DATED: BY: Deputy l L. Hall II. FROM: County Counsel TO: Clerk of the Board of Supervisors (�() This claim complies substantially with Sections 910 and 910.2. (/ `) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: G BY: j6A���y County Counsel III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present This Claim is rejected in full. ,( `) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. IV Dated: A P R 2 11987 PHIL BATCHELOR, Clerk, By Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. APR 2 2 'Q87 Dated: BY: PHIL BATCHELOR by Deputy Clerk CC: County Counsel County Administrator 3.04.3? 7 1 LEON A. BRUNET, ESQ. RAMOS, IIERLIHY, BROADBECK 2 IIEPLER & COCKLE � • Attorneys at Law ' 3 101 California Street, Suite 1870 San Francisco, California 94111-5821 4 Telephone (415) 986-15897 e ,t 5 Attorneys for Claimant, INDUSTRIAL INDEMNITY COMPANY, 6 a corporation 7 8 INDUSTRIAL INDEMNITY COMPANY ) NO. a corporation, ) 9 ) CLAIM FOR DAMAGES Claimant ) 10 ) (Government Code Section 910) VS. ) 11 ) CITY OF ORINDA, CONTRA COSTA ) 12 COUNTY, STATE OF CALIFORNIA, ) 13 Defendants. ) 14 15 TO: 16 INDUSTRIAL INDEMNITY COMPANY, a corporation, hereby presents 17 this claim for any and all Workers' Compensation benefits it may be called upon to 18 pay, on behalf of DAVID CLIFFORD, to the Contra Costa County , 19 pursuant to Section 910 of the Government Code of the State of California, and 20 makes the following statements in support of the claim: 21 1. The name and mailing address of this Claimant is: INDUSTRIAL 22 INDEMNITY COMPANY, P.O. Drawer "E", Valnut Creek, California 94596. 23 2. The address to which the Claimant desires notice to be sent is: 24 LEON A. BRUNET, Ramos, Herlihy, Broadbeck, Hepler &' Cockle, 101 California 25 Street, Suite 1870, San Francisco, California 94111, telephone number (415) 26 986-1589. 27 3. The date and place of the occurrence giving rise to this claim is 28 December 11; 1986 on rilinor Road, approximately 2/10 of a mile east of Camino -1- 5X504 (4/84) 1 Pablo, City of Orinda, County of Contra Costa, State of California. 2 4. The circumstances giving rise to this claim are as follows: 3 On December 11, 1986, at approximately 1:00 P.M. , DAVID CLIFFORD 4 was working on Minor Road, approximately 2/10 of a mile east of Camino Pablo in 5 the City of Orinda when he was struck by a passing vehicle. At the time of the 6 accident MR. CLIFFORD was working for TELEVENTS and involved in the 7 installation of cable television lines on utility poles adjacent to Minor Road. Due 8 to the excessive narrowness and inadequate shoulders on the roadway MR. 9 CLIFFORD was required to perform his job duties in dangerously close proximity 10 to through traffic which resulted in his being struck, as aforesaid. 11 5. As a direct and proximate result of the aforementioned collision, 12 DAVID CLIFFORD suffered multiple injuries, the full nature and extent of which 13 are not yet known, but which have resulted in necessary and incidental medical 14 expenses for the care and treatment of said injuries. This claimant alleges on 15 information it believes that said injuries are permanent and that there will be 16 future medical expenses to cure or relieve the effects of the aforesaid injuries 17 and future loss of earning capacity. 18 6. At all times material to this Notice of Claim, DAVID CLIFFORD was 19 employed by TELEVENTS which at all times mentioned herein was insured under a 20 policy of workers' compensation insurance whereby INDUSTRIAL INDEMNITY 21 COMPANY was and is obligated to discharge the liability of said employer for 22 workers' compensation benefits required or imposed under the California Labor 23 Code. 24 7. At all times herein mentioned, Contra Costa County its 25 agents and employees, while acting within the course and scope of said 26 relationship, negligently and carelessly owned, operated, maintained, constructed, 27 designed, inspected, repaired, warned, or failed to warn the general public of 28 the dangerous conditions pertaining to the aforesaid Minor Road where DAVID -2- 5X504 (4/84) 1 CLIFFORD was injured, so as to cause the aforesaid injuries, including, but not 2 limited to the creation of a dangerous condition and the allowance of a dangerous 3 condition to exist due to the aforementioned road's excessive narrowness, and 4 inadequate shoulder. 5 8. As a direct and proximate result of the aforesaid tortious acts or 6 omissions by Defendants, and each of them, DAVID CLIFFORD was caused to 7 sustain multiple injuries and INDUSTRIAL INDEniNITY COMPANY is informed and 8 believes that it will be required to pay further workers' compensation benefits as 9 herein claimed. 10 9. The names of the public employees causing injury to DAVID 11 CLIFFORD are unknown at this time. 12 10. The exact amount of the claim by INDUSTRIAL INDEMNITY 13 COMPANY is presently unknown, however, for purposes of this claim, claimant 14 assigns a maximum value of $200,000 to its claim. 15 DATED: March 20, 1987 LAV OFFICES OF RAMOS, IIERLIIiY, BROADBECK, IIEPLER & COCKLE 16 17 By: 18 LEON A. BRUNET, y for INDUSTRIAL INDEMNITY 19 COMPANY, a Corporation 20 21 22 23 24 25 26 27 28 -3- 5X504 (4/84) CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT April 21 , 1987 and Board Action, All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: Unspecified Section 913 and 915.4. Please note all "War n s" �Vurity Counsel CLAIMANT: JOHN R. DOUGLAS MAR,2 3 1987 ATTORNEY: Date received Martinez CA 94553 ADDRESS: 2900 Chevy Way BY DELIVERY TO CLERK ON March 23 , 1987 San Pablo, CA 94806 BY MAIL POSTMARKED: March 20 , 1987— I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. DATED: March 23 , 1987 gaIl Deputy OR, Clerk o nn Cervelli II. FROM: County Counsel TO: Clerk of the Board of Supervisors (X) 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 fate and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: ��2_ BY: .�ty County Counsel III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present (�() This Claim is rejected in full. (, `) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date.A r n t p Dated: R 2 •t 1907 PHIL BATCHELOR, Clerk, By ' Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. AFFIDAVIT OF MAILING I declare under penalty of perjury that. I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order a otice to Claimant, addressed to the claimant as shown above. IAPR 2 2 1987 Dated: BY: PHIL BATCHELOR by Deputy Clerk CC: County Counsel County Administrator CLA.IN TO. BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY Instructions to Claimant A. Claims relating to causes of action for death or for injury to person or to personal property or growing crops must be presented not later than the 100th day after the accrual of the cause of action. Claims relating to any other cause of action must be presented not later than one year after the accrual of the cause of actiop•_ (Sec. 911. 2, Govt. Code) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street, Martinez , CA 94553 (or mail to P.O. Box 9.11, Martinez, CA) _ C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. E. Fraud. See penalty for fraudulent claims , Penal Code Sec. 72 at end of this form. RE: Claim by ) ResL��ECorl for Clerk' s fi ing stamps ) IVED 1987 Against the COUNTY OF CONTRA COSTA) ofSSU ERVSM or DISTRICT) cosi ' Dewy (Fill in 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 di�d the damage or injury occur? (Include-city and county) ------------ ------------------------------------- --- 3. How did the damage or injury occur? (Give full details use extra sheets if required) � ����✓ �- ��� ���P�J „!,d ,�2�--rY� O ------------------------------------------------------------------------ 4. What part-icular act or omission on the part of county or district officers , servants or employees caused the injury or damage? (over) 5. What; are the names of county or district officers, , sex.vants ,or=_ ..r I employees causing the damage or injury? C j y�r F•e lax .s. ------------------------------------------------------------------------- 6. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage) f - - -- - - ----------------------------------------------- 7-.--H-ow--was----th-e--amoun----t--cl-aimed above computed? (Include the estimated amount of any prospective injury or damage. ) ------------------------------------------------------------------------- 8. Names and addresses of witnesses, doctors and hospitals. _ ..�.•.....a.,M....�.._,,.,..,,.,....... _ 9. L s p- ad'' u e you made on account of this accident or injury: -twit i )I � ITEM AMOUNT Govt. Code Sec. 910.2 provides : "The claim signed by the claimant SEND NOTICES TO: or by some pers Ion ori his behalf. " Name and Address of Attorney Claimant' s Signatu Add, ss Telephone No. Telephone No. � NOTICE Section 72 of the Penal Code provides: "Every person who, with intent to defraud, presents for allowance or for payment to any state board or officer; or to any county, town, city district, ward or village board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account, voucher, or writing, is guilty of a felony. " -g 44, ' o BONDS BODY SHOP 1507 Market Ave. San Pablo, CA 94806 Phone 233-1003 Date ADD?XS8 IEEUy M A WR YF4 AR V MODF* 100 -:110A MdI'OR_ SPIUAL — ]AUXAGE WENSE.70702F INS.CO ADJUSTER- - Symbol FRONT Labor1 CoLor Hrs.Parts Symbol Left Labor$Labor Hrs. Parts Symbol RIGHT Lobar$Labor Hrs.Parts Bumper Hood Side Hood Side Bumper Brkt. Fender, Fri. Fender, Fri. Bumper Gd. Fender Shield Fender Shield Fri. System t:�F�ender Mldg. Fender Midg. Frame dlamp Heodlomp Headlamp Door Headlamp Door Sealed Beam Sealed Beam Cowl Cow; Windshield Windshield Door, Front Door, Front Door Hinge Door Hinge Door Gloss Door Glass Door Midg. Door Midg. Center Post Center Post Door Rear Door Rear Door Glass Door Glass Door Midg. Doo; Midg. Rocker Panel Recker Panel Grovel Shield Rocker Midg. Rocker Mldg. — Park Light Floor Floor Rad. Grille, Ctr. Quar. Panel Grille Midg. Quar. Mldg. , Quar. Midg. Quor. Gloss Quar. Glass Fender, Rear Fender, Rear REAR MISC. Bumper Bumper Brkt. Lock Plate, Lr. Bumper Gd. _ Lock Plote, Up. Hood Top Lower Panel Hood Hinge Floor Top Hood Mldg. Trunk Lid Tire Rod. Sup. Battery Rod. Core Tail Light Point t ;0 Anti Freeze Undercoat Frame Wheel RECAPITULATION LLr% Labor Hours-3 ata � Q�,,cc Parts 6 Material $ Sublet b Net Items _$ . Other Clwrpe- $ Straighten fMBOLS: N—New A-Alips S—'WM R.Poir ON—Overhaul TOTAL —.L 0 Repair ESTIMATE AND REPAIR ORDER BAY AREA FRAME BODY ALIGNMENT 2218 MARKET STREET —SAN PABLO,CA 94806 Co. Reg. 43701 Ph. 233.1448 SHEETNO OF SHEETS Car Owner �La LASS Business Phone Date - TV �Address o —,`tIL4 Home PAOne Est No Repair Older rder no Insurance Co — Retain ❑ Customer Initial I D Adjuster Parts A R M A M�QgE L L I C E N S E N O SPEEDOMETER Destroy b o►L✓D 1 ��� i.2- Paris ❑ LABOR DESCRIPTION OF LABOR i X Q x o� • 3 Z2. S 777I I HRS OF LABOR p S PERHR S i the above estimate is based on our Inspection and s not cover additional parts or la r ESTIMATE AMOUNTS PARTS S Which may be repwrad after Ino work has started Worn or damaged parts not evident on first — ,nSOecbon may be discovered and you will be contacted for authorization for additional PAINT Revised Estimate S MATERIALS work Parts prices subject to change without notice This estimate is good for - days BODY S............insurance Deductible Estimator....................................... Customers 0K By MATERIALS ACKNOWLEDGEMENT I have read and understand the above estimate and authorize repair SUBLET service be performed Including sublet work. and acknowledge receipt of this estimate An Tim! Date CElled By Wnom express mechanic s lien IS hereby acknowledged-On above car duck. or vehicle to secure TAX the amount of repairs mereld ADVANCE THIS WORK AUTHORtZEDBV DATE Deposit CHARGES _ WORK ACCEPTED 13Y DATE Chgs It not Repaired S TOTAL 'CODE N NEW U USED R REBUILT A CLAIM t BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Pgainst the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT April 21 , 1987 and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: X100 ,000. 00 Section 913 and 915.4. Please note all "W06W q Counsel CLAIMANT: R.N. STEFAN ET AL c/o Edward E. Rockman, Golden, Stefan, Ellenberg & Toby MAR,2 G1987 ATTORNEY: A Professional Corporation ort Street ; 460 � Martinez, CA 84553 7677 Oak port � Date received ADDRESS: Oakland, CA 94621 BY DELIVERY TO CLERK ON March 20, 1987 BY MAIL POSTMARKED: March 4, 1987 Certified P 316 113 088 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. DATED: March 20, 1987 g�IL BATCHELOR, Clerk _ y L. Hall II. FROM: County Counsel TO: Clerk of the Board of Supervisors (�( ) This claim complies substantially with Sections 910 and 910.2. /{(�2 L. w" ( ) 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). �� ��d-L,Gd-Q--. ( Claim is note-Cimely fi d'� The C1ehould return claim on gro d'that it was filed late and send UL warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: dz. LAZL SO, M�7 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. ( g) Other: Portion of original claim not p.r.eviously- returned as untimely is rejected in full. I certify that this is a true and correct copy of the Board's Ordgr entered in its minutes for this date. Dated: APR 2 11987 PHIL BATCHELOR, Clerk, By �� , Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. APR -2v,,,87 ,987 Dated: BY: PHIL BATCHELOR by Deputy Clerk CC: County Counsel County Administrator c t y ` Contra Costa Gounty- t^. r VE,_ 7 LAW OFFICES OF GOLDEN' STEFAN, ELLENBERG & TOBY 1J119(�8y� A PROFESSIONAL CORPORATION 7' r �./ �IeiLQ THEODORE GOLDEN (1907-19711 �I5!)�5Ei9_-3p0 R.N. STEFAN R �CE'VED �g'7q ` t'�inli tratol MARVIN H.ELLENHERG 460 HARRY J.TORY SUITE OAKLAND,CALIFORNIA HOLLY HELMLITH I /f / 9 4621-1967 EDWARD E.ROCKMAN 710 / GEORGE C.ROGERS "a. _� ;W- r PH ATO P�EgllV S CERTIFIED MAIL K NT o t fl.o D TO: County of Contra Costa MAR 5 - 1987 RE: Claim for Damages CONTRA COSTA COUNTY Brought by BUILDING INSPECTOR R. N. Stefan, Mark Stefan and Lisa Stefan, claimants Pursuant to Government Code 55905 and 910, the following claim is presented on behalf of R. N. Stefan, Mark Stefan and Lisa Stefan for damages caused to their property by the City of Orinda. 1. Claimants' post office address is 8 La Plaza, Orinda, California. 2. Notices concerning the claim should be sent to Edward E. Rockman, Golden, Stefan, Ellenberg & Toby, A Professional Corporation, 7677 Oakport Street, Suite 460, Oakland, California 94621. 3. Claimants R. N. Stefan and Mark Stefan are co-owners of that certain real property commonly known as 8 La Plaza, Orinda, California consisting of a single family residence. Claimant Lisa Stefan is the wife of Mark Stefan and she and Mark Stefan make their home and reside at 8 La Plaza, Orinda, California. The City of Orinda owns and maintains the street Linda Vista which lies to the east and up a steep hillside from La Plaza and the street Camino Sobrante which lies to the west and downslope from La Plaza. The City of Orinda or its predecessor in interest constructed a catch basin and drain which collects water from the hillside lying to the east of Linda Vista at a location approximately adjacent to 47 Linda Vista. From there the water flows through a pipe underneath Linda Vista and discharges into another catch basin on the hillside to the west of Linda Vista and adjacent to 54 Linda Vista. From there, the water enters another pipe which transports it down slope to a point on the hillside to the south of 52 Mira Loma. From there the water travels by a concrete channel for approximately 15 feet before entering another pipe which again transports it down slope before discharging it into a pipe which surfaces at the top of the La Plaza cul-de-sac. The La Plaza pipe then travels underground before surfacing and discharging its water onto Camino Sobrante. The City of Orinda or its predecessor in interest have been discharging water into the La Plaza pipe for an unknown period of time but exceeding five (5) ,years from the claimants discovery of the use. Neither claimants nor their predecessors in interest, nor others with a property interest in the La Plaza pipe, ever granted the City of Orinda or its predecessor in interest permission to use the La Plaza pipe. La Plaza is a private road in which claimants have a property interest. The City of Orinda and its predecessor in interest use of the La Plaza pipe has been actual, open, continuous, uninterupted, adverse, under a claim of right, and notorious for greater than five (5) years thus constituting a prescriptive use of the La Plaza pipe. The County of Contra Costa is the predecessor in interest of the City of Orinda. The County of Contra Costa had jurisdiction over the territory which is now the City of Orinda until July 1, 1985. From July 1, 1985 until July 1, 1986, the County of Contra Costa provided services to the City of Orinda including services for the maintainance and repair of the drainage system including the La Plaza pipe. 4. Neither claimants' property, nor the properties of the other homeowners situated on La Plaza discharge water into the La Plaza pipe. The La Plaza pipe has fallen into such disrepair that it no longer has structural integrity. The water has broken through the pipe and through the surface of the roadway creating a hole. The hole has expanded and is undermining the concrete driveway of claimants' property at 8 La Plaza. The water from the pipe first burst through the surface of the La Plaza roadwav on or about February 15, 1986. Efforts were undertaken by claimants and others to contain the water by filling in the hole but with each new rainstorm, the repair efforts failed and the hole continued to grow. On or about October 12, 1986, the source of the water being discharged into the La Plaza pipe, i.e. the catch basin and pipes draining the hillside at Linda Vista, were discovered by claimants. On that same date, a letter was sent to the City of Orinda seeking its assistance. To this date, the City has failed and refused to undertake maintenance and repair of the La Plaza pipe causing current damage to claimants. The failure of the County of Contra Costa to maintain and repair the La Plaza pipe was a substantial cause of its deterioration creating damages set forth below. The failure of the County of Contra Costa to maintain and repair the La Plaza Pipe has caused physical injury to the real property of the claimants. The damage caused by the La Plaza pipe also obstructs the free use of claimants' property, obstructs the free passage and use of the La Plaza roadway, diminishes the value of claimants' property, interfers with the comfortable enjoyment of claimants' property, and constitutes a taking for public use without just compensation all to claimants' special and general damage. 5. The names of the public employees causing claimants' injuries are unknown at this time. 6. At the time of the presentation of this claim, the amount required by claimants to repair the La Plaza pipe is not precisely known but will exceed the amount of $20,000.00. The amount necessary to compensate claimants for the damage to their real property, including diminution in value of their property at 8 La Plaza, Orinda, ' California is not precisely known, but estimated to be in the area of $100,000.00. The amount of damages for claimants' annoyance, discomfort, inconvenience, and mental suffering is $50,000.00 each. The total amount of damages as of this date is $270,000.00. DATED: March 4, 1987. GOLDEN, STEFAN, ELLENBERG do TOBY A Professional Corporation By: EDWARD E. ROCKMAN CLAIM BOARD G'-SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT AU r i 1 21, 1 9 F 7 and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California_Government Codes. ) the action takenron your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: $2 ,141.40 Section 913 and 915.4. Please nFACIOVEPrnings". CLAIMANT: RALPH GRIFFIN MAR 13 1987 c/o Kent C. Wilson COUNTY COUNSEL ATTORNEY: 1350 Treat Blvd. #400 MARTINEZ, CALIF Walnut Creek, CA 94596 Date received ADDRESS: BY DELIVERY TO CLERK ON March 10 , 1987 BY MAIL POSTMARKED: March 9 , 1987 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. IL BATCHELOR, Clerk DATED:_ March 12, 1987 �a; eputy L. Hall II. FROM: County Counsel TO: Clerk of the Board of Supervisors ( ) This claim complies substantially with Sections 910 and 910.2. ( This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: 3y YY BY: puty County Counsel III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present This Claim is rejected in full. (� �) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: APR 21 1987 Deputy PHIL BATCHELOR, Clerk, By ���"--� , Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant l,as shown above. Dated: ~ 2 2 198/ BY: PHIL BATCHELOR by r Deputy Clerk CC: County Counsel County Administrator WILSON & ROSE ATTORNEYS AT LAW KENT C. WILSON A PROFESSIONAL ASSOCIATION BERNARD F. ROSE URBAN WEST I 1350 TREAT BOULEVARD SUITE 400 WALNUT CREEK,CALIFORNIA 94596 TELEPHONE:(415)933-4500 rf01i��� March 9, 1987 :RECEIVEDJ AR /to)Mr. George Colman HAYT, HAYT & LANDAU P. 0. Box 4057 Woodland Hills, CA 91367-4057 .1.. RE: Our Client RALPH GRIFFIN Your Client: CONTRA COSTA COUNTY HHL File No: L465-421 Amount Due $2, 141 .40 Dear Mr. Colman: This will acknowledge your letter of February 19, 1987. As I explained to Myrobi of your office, a review of the medical records reveals that none of the care and treatment rendered to MR. GRIFFIN from the County Hospital was appropriate. MR. GRIFFIN was suffering from lithium poisoning when admitted. The County Hospital not only failed to properly diagnose but continued to give MR. GRIFFIN more lithium. On behalf of MR. GRIFFIN, I am claiming damages as the result of lithium poisoning and for no other reason. As a result, your claim is denied and no monies will be paid by this office. Myrobi stated that your office needed to further review the matter. The same day your office made such a promise, your letter referred to above was mailed. This is evidence of your bad faith. It is obvious that you do not care that the lien is invalid. Any further activity on your part to collect will be viewed as an unfair collection practice and the appropriate tort action will filed against yourself as well as Contra Costa County. VOC. WILSON u , K KCW/pg cc: Public Agency Claims Service Members of the County Board of Supervisors CLAIM BOARD OF SUFMISORS OF CONTRA COSTA COUNTY, CALIFORNIA Gla,',n Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT _ Aa r i 1 21, 1987 and Board Action. All Section references are to ) The copy of this document mailed to yogi is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: $900 . 00 Section 913 and 915.4. Please notelrk�lE1,W?i rings". ED CLAIMANT: GERALD BREUNER MAR V 4114 Goodrick Ave.' 3 1987 ATTORNEY: Richmond, CA 94801 COUNry UNSEL Date received MARTI E7 C,y ADDRESS: BY DELIVERY TO CLERK ON March 12, YF9.87 BY MAIL POSTMARKED: March_ 10., 1987 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. March 12 19.87 PpHHIL BATCHELOR, Clerk DATED: BY: Deputy L. Hall II. FROM: County Counsel TO: Clerk of the Board of Supervisors ( ) This claim complies substantially with Sections 910 and 910.2. This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Qate d: ��1JL, , �98? BY:� (• 4-'A Deputy County Counsel III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present (�) This Claim is rejected in full. (( \) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. APR 21 1987 Dated: PHIL BATCHELOR, Clerk, By Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today 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: APR 2 2 1987 BY: PHIL BATCHELOR by • Deputy Clerk CC: County Counsel County Administrator CLAIM`M: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY Instructions to Claimant A. Claims relating to causes of action for death or for injury to person or to personal property or growing crops must be presented not later than the 100th day after the accrual of the cause of action. Claims relating to any other cause of action must be presented not later than one year after the accrual of the cause of action. (Sec. 911. 2, Govt. Code) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street, Martinez , CA 94553 (or mail to P.O. Box 911, Martinez, 'CA) C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at end of this form. RE: Claim by )Reserve W' stamps RECEIVED MAR I Against the COUNTY OF CONTRA COSTA) orsv - ) '?�7 DISTRICT) (Fill in 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: ------------------------------------------------------------------------ d 1. When did the amage or injury occur? (Give exact date and hour) C-0, 2. Where did-the damage or injury occur? (Include city and-County) ------ - - ------ ---------------------------------------------------- 3. How did the damage or injury occur. (Give full details, use extra sheets if required) ------------------------------------------------------------------------ 4. What particular act or omission on the part of county or district officers , servants or employees caused the injury or damage? (over) P' y • 5. What are the names -of county or district officers, .servants: �,.. I. employees causing the damage or injury? Z 'a c5f,"',- ' - ------ ------------------------------------------------ -- --------- ------- 6. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage) � ' a__ A-174*1 ------------------- ---------------------- 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage. ) Cer�' ------------------------------------------------------------------------- 8. Names and addresses of witnesses, doctors and hospitals. -- ---------------------------------------------------------- 9. L e� res you made on account of this accident or injury: ITEM AMOUNT iIMOJl Yti1%.i� aia i1^A'�3;A D�-. Govt. Code Sec. 910.2 provides: "The claim signed by the claimant SEND NOTICES TO: (Attorney) or by some person on his behalf. " Name and A dress of Attorney Claimant' s Signatur e �res9 Telephone No. Telephone No. ************************************************************************** NOTICE Section 72 of the Penal Code provides: "Every person who, with intent to defraud, presents for allowance or for payment to any state board or officer, or to any county, town, city district, ward or village board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account, voucher, or writing, is guilty of a felony. " CLAIM IWIPIR ED BOAR.. OF SUPERVISORS OF CONTRA COSTA COUNTY, CAL 41aim Against the County, or District governed by) MAR 13 198?OARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT COUNTY COUNSE[ April 21 , .1987 and Board Action. All Section references are to ) The copy of this documer�i d c1Q1#ou is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: X100, 000. 00 Section 913 and 915.4. Please note all "Warnings". CLAIMANT: JACOB EASTERWOOD, A MINOR, BY AND THROUGH HIS GUARDIAN AD LITEM, CHERYL EASTERWOOD AND CHERYL EASTERWOOD ATTORNEY: c/o Michael C. Scranton 1200 Concord Ave. #260 Date received ADDRESS: Concord, CA 94520 BY DELIVERY TO CLERK ON March 12 , 1987 BY MAIL POSTMARKED: March 11 , 1987 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. March 12 1987 EaIL BATCHELOR, Clerk DATED: eputy L. Hall II. FROM: County Counsel TO: Clerk of the Board of Supervisors ( ) This claim complies substantially with Sections 910 and 910.2. This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: �S BY: �. ��t•� D puty County Counsel III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present (x) 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. t ✓ Dated: APR 21 1987 PHIL BATCHELOR, Clerk, Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served.or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. APR 22 1987 Dated: BY: PHIL BATCHELOR byZ3 �—Z--Deputy Clerk CC: County Counsel County Administrator 1 1 MICHAEL C. SCRANTON A Professional Corporation 2 1200 -Concord Avenue, Suite 260 RECEIVEJ) Concord, CA 94520 3 (415) 682-7777 1 { MAS 14 iT ! 4 Attorney for Claimants OA 5 T 6 7 8 CLAIM AGAINST PUBLIC ENTITY 9 10 In the Matter of the Claim of ) 11 JACOB EASTERWOOD, a minor, by ) and through his Guardian ad ) CLAIM FOR DAMAGES 12 Litem, CHERYL EASTERWOOD and ) (Govt. Code §910, et seq. ) CHERYL EASTERWOOD, ) 13 Claimants ) -against- ) 14 ) COUNTY OF CONTRA COSTA ) 15 ) 16 1. I , MICHAEL C. SCRANTON, the undersigned, present this claim 17 for damages as a person acting on behalf of the claimants. 18 2. I desire notice relative to this matter to be sent to my 19 following business address : 1200 Concord Avenue, Suite 260, 20 Concord, California 94520. 21 3 . The name and address of claimants are: JACOB EASTERWOOD, 22 a minor, and CHERYL EASTERWOOD, 1016 Power Avenue, No. 47, 23 Pittsburg, California. 24 4. The date and place of the occurrence that gave rise to this 25 claim are as follows : January 5, 1987 on Monument Boulevard, 26 Pleasant Hill , Contra Costa County, California. 27 28 /// 1 5. The circumstances of the occurrence which gave rise to 2 the claim are: School teacher and/or teacher's aide, negligently 3 failed to secure minor claimant' s wheelchair in a school bus. 4 During transit, the wheelchair tipped over, proximately causing 5 injuries to minor claimant. 6 6. A general description of claimant' s injuries, damages, 7 and losses incurred so far as is now known are as follows: Minor 8 claimant hospitalized. Injuries not known at this time. 9 7. If known, the name (s) of the public employee (s) causing 10 said injuries, damages, and losses is/are : Public employees 11 not known at this time. School involved was, however, Martin 12 Luther King School, Pittsburg, County of Contra Costa, California. 13 8 . The amount claimed as of the date of presentation of 14 this claim consists of general damages and special damages 15 relative to claimant' s injuries and property damage and loss of 16 use of same in amounts unkown at this time but in the aggregate 17 not less than $100, 000. 00 and exceeding the jurisdiction of the 18 Municipal Court of the State of California. Claimant reserves 19 the right to insert said amounts when same are ascertained. 20 Dated: March 11, 1987 . 21 22 41WAE C. SCRANTON 23 /Attorney for Claimants 24 25 26 27 28 -2- ti PROOF OF SERVICE B.Y MAIL (C.C,P, 1013A, 2015 .5) STATE OF CALIFORNIA COUNTY OF CONTRA COSTA I am a citizen of the United States and a resident of the county of Contra Costa. I am over the age of eighteen years and not a . party to the within above-entitled action. My business address is 1200 Concord Avenue, Suite 260 , Concord, CA 94520 . On March 11, 1987 I served the within CLAIM FOR DAMAGES (Govt. Code §910, et seq. ) on the parties in said action, by placing a true copy ther eof enclosed in a sealed envelope with postage thereon fully pre:i�aid, in the United States mail at Concord, California, addressed as follows : Clerk - Board of Supervisors Contra Costa County County Administration Building 651 Pine Street Martinez, CA 94553 I, Joan M. Ritter, certify (or declare) , under penalty of perjury that the foregoing is true and correct. Executed on March 11, 1987 at Concord, California. CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT Ap r i 1 21, 1987 and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: Unspecified Section 913 and 915.4. Please note all C H94p�}sgounsel CLAIMANT: MICHAEL 11. 0'NEAL MAR-.2 6 1987 1893 Sagewood Court ATTORNEY: Concord, CA 94521 Martinez, CA 94553 Date received ADDRESS: BY DELIVERY TO CLERK ON March 20, 1987 hand del. BY MAIL POSTMARKED: no envelope I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. IL gATCHELOR, Clerk DATED: March 20, 1987 gy: Deputy L. Hall II. FROM: County Counsel TO: Clerk of the Board of Supervisors ( ) This claim complies substantially with Sections 910 and 910.2. (� This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: �� BY: t Deputy County Counsel III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present ( This Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. APR 21 1987 Dated: PHIL BATCHELOR, Clerk, By. Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today 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: APR 2 2 1987 BY: PHIL BATCHELOR by Deputy Clerk CC: County Counsel County Administrator CLAIM TO: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY Instructions to Claimant Return original application to Clerk of the Board 651 Pine St., Room 106 Martinez, CA 94553 A. Claims relating to causes of action for death or-'"for Injury to person or to personal property or growing crops must be presented not later than the 100th day after the accrual of the cause of action.- Claims relating to any other cause of action must be presented not later than one year after the accrual of the cause of action. (Sec. 911.2, Govt. Code) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street, Martinez , California 94553. C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. . E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at end of this form. RE: Claim by )Reserved for Clerk's filing stamps RECEIVEI) Against the COUNTY OF CONTRA COSTA) CA ) n 7 or DISTRICT) / / (Fill in name ) ow The undersigned claimant hereby makes claim a Contra Costa or the above-named District in the sum of $ and in support of this claim represents as follows: — s------- --------- — —.. i. When did the damage or injury occur? Give exact date and �iourj �. Where did-tie damage or injury occur? �Inciude city and county] 3'. How did the damage or injury occur? (Give Tula detai.Is, use extra sheets if required) 4. What particular act or omission on the part of county or district officers , servants or employees caused the injury or damage? f—e a P-a Ile 7� o 'eke z h �avca0 oGt JLb (over) 5. *What are the names of county or district officers, servants or'• employes causing the damage or injury? T—lam'—T—••--------- —T----�•— —��- 6. What damage or injuries do you claim resulted? Give-full extent of injuries or damages claimed. Attach two estimates for auto damage) 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage. ) 8. Names and addresses of witnesses, doctors and hospitals. ka 1-r ei- Ice J- e �.- Llst the expenditures you-made on account of this accident or injury: DATE h ,. ITEM AMOUNT -4 3- 7 q 'OP 74 -/3- �r7 Govt. Code Sec. 910.2 provides : "The claim signed by the claimant SEND NOTICES TO: (Attorney) or by some person on his behalf. " Name and Address of Attorney Claimant's Signature .7 la fe �11111 AO/ Zly Address C4 I Yr 2 Telephone No. Telephone No. yid 71k- NOTICE Section 72 of the Penal Code provides: "Every person who, with intent to defraud, presents for allowance or for payment to any state board or officer, or to any county, town, city district, ward or village board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account, voucher, or writing, is guilty of a felony. " CONTRA COSTA COUNTY SUPERVISOR'S OCCUPATIONAL INJURY OR ILLNESS REPORT PROCEDURES BACKGROUND The Supervisors Report is developed to establish that an employee alleges to have an on-the-job injury or illness, that the individ- ual alleging injury is an employee. It is an attempt to document the injury and the situation causing the injury. COMPLETION OF REPORT(AK30) PART A - All questions on the report should be completed by the immediate supervisor and submitted within 24 hours directly to the County,Safety Office. If a question cannot be answered, do not delay filing this report. Send additional information as soon as possible. TELEPHONE REPORTS If an injury is serious and requires drastic emergency care or hospitalization or causes death, it must be reported to the Safety Office by telephone as soon as possible, but no more than 24 hours after it happened. If an injury causes disability from work on any days beyond the date of injury, it must be reported by telephone on the first day of disability beyond the date of injury. These telephone reports must be followed by written reports of injury as soon as possible. QUESTIONS, PROBLEMS, REPORT DISCREPANCIES OR UNUSUAL DELAYS If the reporting department is aware of any questions, problems, discrepancies, or unusual delays on any report submitted, an attached statement from the department should provide the needed explanation. WORK INJURY INVOLVING AUTO ACCIDENT In addition to submitting the AK30, if injury involves use of a County or personal car, statement is to be attached showing follow- ing: (a) Name, address and insurance carrier of other driver. (b) Were police called? (If yes, name of police department; was a citation issued?) (c) Was employee driving car while on county business? (d) Was employee paid mileage for this trip? If so,what was origin and destination of this trip? INJURY REPORT INFORMATION AND FORM AVAILABILITY Any questions about injury reports or medical care should be telephoned to the Safety Office, ext. 2926. Additional injury report forms are available from the Safety Office. ` COUNTY OF CONTRA COSTA Personnel Department - Safety Office 651 Pine Street, Room 103 Martinez, CA 94553 372 - 2926 TO DOCTOR (FOR YOUR INFORMATION) All Contra Costa County employees must be provided with a WRITTEN release to full duty before being allowed to return to their job. Please provide our employee with same. Should you wish to have a detailed job description for an injured employee, please contact our office. If a light duty release is possible, arrangements may possibly be made for specified time period (i.e. 2-3 weeks). Should you feel a light duty assignment is feasible, please send a clarified written statement to our office describing the light duty assignment. In all instances light duty is for the sole purpose of returning an injured employee to full duty at the end of the light duty period. The "Doctor's First Report of Work Injury" may be sent to our program administrator with a copy to the County at the above address. CONTRA COSTA COUNTY SAFETY DIVISION 372-2926 SCOTT WETZEL SERVICES, INC. 148.5 Enea Court, Suite 1100 Concord, CA 94520 676-0388 + CONTRA COSTA COUNTY SAFETY OFFICE (DO NOT COMPLETE(- SLI f fRVISC?,R'S,REPORT OF` 651 Pine Street - Room 103 OSHA CASE NO FORM 5020 SENT OCCUPATIONAL.INJURY OR ILLNESS Martinez, CA 94553 (415) 372-2926 W 1.NF ME.. / /��. /f A ' / 2,AGE 3.SEX MALE .0 FEMALE 4 KOME ADDRESS`Nulabz'j,bfreet fiify�7,f?l O/T e d.- W /h Gr// 1 / S.HOME IL // — PHONE NO. 6,DEPARTMENT/ 6-A 9RGANIZATION a7 7.CLASSIFICATION(TITLE OF JOB) W DIVISION 8, HERE DID INJURY'I>R.JEXPPSy3E OCCUR?�Addrps,dry,Coygry) F , 9.ON EMPLOYERS //�,•/_ ^'.• PREMISES ❑ YES ❑ NO 10.WHAT T SK WAS EMIM PLOYEE DOING WHEN IN R 0 Iii. .ag a patent,fdin9leports,capturing on animal,etc.) UG' It/c! cY I I HOW DID THE INJURY OR EXPOSURE OCCUR? (Please describe fully the events that resulted in injury or occupational disease Tell what nhappened and how it happened.Use separate sheet if necessary.) i,,v!-. All /rf o c 12.0B�5-OR SUBSTANCE-)THAT Del CTLY ITURED EMPLOYEE(ie machine,fumes,floor,desk.person,tool,baK,ommol,vehicle,etc, Vf I✓f W 3,fl.ATURE—F IN1}dR/�9R•tLI Lt /�AI , TF BCCI AEFEC> D % I�/': /c/�� '+ '/'-' % l�� •� _ �; ((// J / J 14 DATE OF INJURY I,AAONTH I DAY YETAR 115 TIME A,M.O 16.DID THIS INJURY RESULT IN EMPLOYEE LEAVING WORK OR ILLNESS / , OF DAY ~ �J< AT ANY TIME?!F YES,GIVE DATE LAST WORKED. YES DATE D NO CK 17.HAS EMPLOYEE RETURNED TO WORK? NO LOST TIME 18 ?.DID EMPLOYEE DIE 19. 1)A14 Y..� DATE DATE 1 WERE INFORMED. � 7" J,) Z C] YES RETURNED ❑ NO(Still off work) ❑ YES DECEASED ❑ NO OF INJURY 20.WAS INJURED EMPLOYEE SEEN BY A PHYSICIAN? If yes,give name&address: ❑YES ❑ NO W W IF HOSP t+ZED>NAME 8 ADDRESS OF HOSPITAL a 22 IN THE EVENT ABOVE ACCIDENT RESULTED IN DEATH OR SERIOUS ILLNESS INVOLVING HOSPITALIZATION OF MORE THAN 24 LU HOURS.DID YOU REPORT IT TO THE CALIFORNIA DIV!SION OF INDUSTRIAL SAFETY? DATE PHONE 6765333 ❑ YES NOTIFIED ❑ NO `23'C4MPLET fl7 IMMEMAJE1SUPERy>OR'Type or pnnti TITLE WORK PHONE EXT ' //7 SIGNATURE OF DATE ��> ^•� IMMEDIATE SUPERVISOR' IF INFORMATION AVAILABLE PLEASE COMPLETE!TEM 24 THRU 30,BUT DO NOT BELAY REPORT IF UNKNOWN 24 EMPLOYEE NO 25 STATUS _��CJC�LSijj�ITY�IO /5, Zt� DATE OF "DAY 'EAR ❑ PERM ❑TEMP �U 1 7 J / / • BIRTH 3 1 t} fI 28.WAGES AT TIME ❑ MONTHLY I 29 IF HOURLY PER DAY NO.DAYS PER WEEK 30.DATE OF HIRE OFINJURY NUMBER OF MO DA YR S ❑ HOURLY 1.HOURS WORKED THE FOLLOWING INFORMATION IS INTENDED TO ASSIST THE INJURED EMPLOYEE AND MANAGEMENT TO PREVENT FUTURE INJURIES AND IS NOT TO BE USED FOR ANY PUNITIVE ACTION. 3,! IF EMPLOS UNABLE TO DO FUJI DUTY CAN APPROPRIATE LIMITED DUTY BE MADE AVAILABLE. Q'YES NO IF NO.' /1-41N 3? LIST NAMES AND ADDRESS OF WITNESSES AND.ANY PADTIONAL FACTS THAT MIGHT BE PERTINENT of more spore is needed use Z `3 Ataoem onoivs,s pertormeo by'check a$many os opp+opr ore, OI Inured employ( f.i`)�~ J f Supervisor ./ Departmental Safety Caord�no�or work Grovp r� 0 Solely Comm0lee O Other.speofs WEveny or cono,ons»-rn co-a,ovted to occ-dent ' 35 RPcommr.noea❑c+nr,,c .,m .. 36 1,!,,r... „ Z O D 0 mc r-. �p IMMEDIATE SUPERVISOR SIGNATURE DATE DEPT,SAFETY COORDINATOR S•SIGNATURE DATE Te be completed, Signed and forworcel To tr;e Count,, Safety Office within 7 work days of The injury Yellow - Safety Office Copy Blue Department Copy Pink - ,• pr's Copy CONTRA COSTA COUNTY SAFETY OFFICE IDO NOT COMPLETE) SUPE"�*►SOR'S REPORT OF 651 Pine Street - Room 103 OSHA CASE NO. FORM 5020 SENT OCC--)ATII)NAL INJURY OR ILLNESS Martinez, CA. 94553 (415) 372-2926 UJI.NAME r) 2.AGE 3.SEX UA E' V 43� /❑'MALE ❑ FEMALE U4.H M A DRESS W ber,Street.City,Z,p�iJ .,,�( 5.HOME % wCT ca C[ !. _ [+f e.rr W r 9<<l2 ! PHONE NO- 6.DEPARTMENT/ 6A.OR�,AN ATION p 7.CLAS$IFICATI O TITLE OF JOB) UJ DIVISION �( 8.WyERE DID INJURY OR EXPOSURE CUR?(�4,ess, ity,county) 9.ON EMPL Y R'S �aA PREMISES ❑ YES ❑NO 10.WHAT TASK WAS EMPLOYEE DOING WHEN INJURED?li.e.lifting o patient,filing,reports,capturing an onimal,etc.) d 11.HOW DID THE INJURY OR EXPOSURE OCCUR? (Please describe fully the events that resulted in injury or occupational disease.Tell what happened and how it happened.Use separate sheet if necessary.) 12.OBJECT OR SUBSTANCE THAT DIRECTLY INJURED EMPLOYEE li.e,machine,fumes,floor,desk,person,tool,box,animal,vehicle,etc.) IN �cJO�d•�i9 f� % 0 /- %A W Z 13.NATURE OF�URY OR ILLNESS AND PART OF BODY AFFECTED N / 14.DATE OF INJURY 1 MONTH I DAY I YEAR 15 TIME A.M. P.M. 16.DID THIS INJURY RESULT IN EMPLOYEE LEAVING WORK OR ILLNESS OFDAY lb AT ANY TIME?IF YES.GIVE DATE LAST WORKED. ?• 12 / = YES IDATEI O NO 17.HAS EMPLOYEE RETURNED TO WORK? ❑ NO LOST TIME18 DID EMPLOYEE DIE? 19. DATE YOU J ' DATE DATE WERE NFORM Z ❑ YES RETURNED ❑ NO(Still off work) El DECEASED ❑ NO OF INURY /cJ_�- 20.WAS INJURED EMPLOYEE SEEN BY A PHYSICIAN?'If yes,give name&address) YES ❑ NO W W O21.IF HQSPITALIZED,NAME&ADDRESS OF HOSPITAL J 22.IN THE EVENT ABOVE ACCIDENT RESULTED IN DEATH OR SERIOUS ILLNESS INVOLVING HOSPITALIZATION OF MORE THAN 24 W HOURS,DID YOU REPORT IT TO THE CALIFORNIA DIVISION OF INDUSTRIAL SAFETY? DATE PHONE 6765333 ❑ YES NOTIFIED ❑ NO 23.COMPLETED BY IMMEDIATE SUPERVISOR iType or print) TITLE WORK PHONE&EXT. SIGNATURE OF e' DATE, IMMEDIATE SUPERVISOR IF INFORMATION AVAILABLE PLEASE COMPLETE ITEM 24 THRU 30,BUT DO NOT DELAY REPORT IF UNKNOWN 24.EMPLOYEE NO. 25.STATUS 26.SOCIAL SECURITY NO 27.DATE OF MODAY YEAR ElPERM ❑TEMP ^ BIRTH �/ `q 28.WAGES AT TIME ❑ MONTHLY 29.IF HOURLY PER DAY NO.DAYS PER WEEK 30.DATE OF HIRE OF INJURY NUMBER OF MO DA YR S ❑ HOURLY HOURS WORKED 31 IF EMPLOYEE IS UNABLE TO DO FULL DUTY CAN APPROPRIATE LIMITED DUTY BE MADE AVAILABLE. ❑YES ❑ NO IF NO,PLEASE EXPLAIN 32 LIST NAMES AND ADDRESS OF WITNESSES AND ANY ADDITIONAL FACTS THAT MIGHT BE PERTINENT iif more spore is needed,use separate sheet I ' LJ PART A i (To be completed and forwarded to the County Safety Office within 24 hours of injury. Hold Part B, complete within 7 work days and distribute as indicated on the form.) AK 30 (Rev. 5/84) SAFETY OFFICE COPY y CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT Ap r i 1 21, 1937 and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Qbtity C Amount: $3 , 900. 00 Section 913 and 915.4. Please note all "Warning� 0UnS@,� CLAIMANT: ANTHONY MACALUSO..Route 2 , Box �e 198 7 ATTORNEY: Brentwood, CA2194513 2, C4 945 3 Date received ADDRESS: BY DELIVERY TO CLERK ON March 24, 1987 BY MAIL POSTMARKED: March 23 , 1987 Certified P 589 00.8 787 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. March 25 1987 PpHHIL BATCHELOR, Clerk DATED: BY: Deputy L. Hall II. FROM: County Counsel TO: Clerk of the Board of Supervisors This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: '7 U BY: uty 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. BOA RlD ORDER: By unanimous vote of the Supervisors present `A 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. APR 21 1987 Dated: PHIL BATCHELOR, Clerk, By Deputy Clerk WARNING (Gov, code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today 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. APR 2 9 1987 Dated: BY: PHIL BATCHELOR by Deputy Clerk CC: County Counsel County Administrator cLA7.14 TO: BOARD OF SUPERVISORS OF CONTRA CCW*r Q%PPiication to: Instructions to ClaimantC!erk of the Board Jvf.., k ro 6 M rtinez,Califomia 54553 A. Claims relating to causes of action for death or or injury to person or to personal property or growing crops must be presented not later than the 100th day after the accrual of the cause of action. Claims relating to any other cause of action must be presented not later than one year after the accaual of the -cause of action. (Sec. 911.21 Govt. Code) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street, Martinez, California 94553. C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. . E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 92 at end his form. RE: Claim. by )Reserved for Clerk's filing stamps ' RECEIVED ) Against the COUNTY OF CONTRA COSTA) vn! T�vbttc w Ks s or pA% r1R�1Mu DISTRICT) „f anon (Fill n name ) . The undersigned claimant hereby makes claimagainst t44unty of Contra Costa or the above-named District in the sum of $ !aa and in support of this claim represents as follows: --- --- ---- �. When did the damage or �n3ury occur? (Give exact date an our] - - - -- - -------------- ---- 1. Where 11, a Manage or +n3u±y occur? Inc$ude city and county] 04. 2 EftptQc Aue. BEew4woo4 G.C. C. 3T How did the-damage or injuiry occur? -(Give-�uii-�etaiSs;-use ext=a sheets if required) 4. What particular act or om�asion on the part o� county or distr�et officers, servants or employees caused the injury or damage? hi �p,� p�p )tom Vim© (over) �--�16 Dl &IL U 5.; °What are the names of county or `district officers, servants or' employees causing the damage or injury? - -- ----------- 6. What $amage or injuries coo you claim resulted? ZGive cul extent of injuries or damages claimed. Attach two estimates for auto damage) Loss ,-p vao GDwcect-c Bioc.Aes , &0#V 46 --- �' 7-.-' How was the_amount claimed above computed? (Include the estimate amount of any prospective injury or damage. ) 1 /-S�Ge � ------------------------------------------------------ ----------------- 8. Names and addresses of witnesses, doctors and hospitals. _-T-------------T-_------------------------ tures- -----------__--_-----_______T_-___T-------- _______ T____ V. Lis ,i ou made on account of this accident or injury: IILTr-V 13 W .,,� ITEM AMOUNT 7 `41�d#:) 4 r,.. Govt. Code Sec. 910.2 provides: "The claim signed by the claimant SEND NOTICES TO: (Attorney) or--by some person .on his behalf. " Name and Address of Attorney 1&0 ant s gnature . Z � Add;vss C41. Telephone No. Telephone No.�� NOTICE Section 72 of the Penal Code provides: "Every person who, with intent to defraud, presents for allowance or for payment to any state board or officer, *'.or to any county, town, city district, ward or village board or officer, authorized to alma or pay the same if genuine, any false or fraudulent claim, bill, account, voucher, OX-4 writing, is guilty of a felony. " tuns along fzm?IkL kvLTLUE pluggEd Up wAh *a..lo-l: c� C�E.�R,lg � C'a.lJSIR9 �1.E. w7L�.Z. oVi.'Lpow orL{o oViL down ova o�R,av�l uJI& y and art.-kc, -&r\- oparL w Itis ch � cons�'xuc �d a� dQ�x�Ds blo cX bzsF.mEttit c r ' � J CLAIM - a BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim. Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT Ap r i 1 21, 1987 and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: Unspecified Section 913 and 915.4. Please note all "Warnings". CLAIMANT: MARTHA ALEXANDRIA GONZALEZ �Unty c/o Ropers , Majeski, Kohn, Bentley, Wagner & Kane �1qR ATTORNEY: 655 Montgomery St . , #1600 41a San Francisco, CA 94111 Date received March 24 1987 ADDRESS: BY DELIVERY TO CLERK ON BY MAIL POSTMARKED: March 23 , 1987 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. March 25 , 1987 QQHHIL BATCHELOR, Clerk GATED: 8Y: Deputy Hall I1. FROM: County Counsel TO: Clerk of the Board of Supervisors (� ) This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: � 9 T'2 BY: ty>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. BO�AR/D' ORDER: By unanimous vote of the Supervisors present (x) This Claim is rejected in full. (, )` Other: 1 certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: APR 2 11987 PHIL BATCHELOR, Clerk, By Deputy Clerk f' WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. APR 2 2 1987 V_ X�&�DeputyDated: BY: PHIL BATCHELOR by Clerk CC: County Counsel County Administrator N- F F CLAIM AGAINST COUNTY OF CONTRA COSTA CLAIMANT ' S NAME: MARTHA ALEXANDRIA GONZALEZ CLAIMANT' S ADDRESS: 4628 Pacheco Blvd. , Apt . C Martinez , Ca. 94553 ADDRESS TO WHICH NOTICES ARE TO BE SENT: c/o ROPERS, MAJESKI, KOHN, BENTLEY, WAGNER & KANE 655 Montgomery Street, Suite 1600 San Francisco, Ca. 94111 EXACT LOCATION AND DESCRIPTION SUFFICIENT TO IDENTIFY: Pacheco Boulevard, aproximately 152 feet West of De Normandie Way, in an unincorporated area, Contra Costa County, California HOW DID IT OCCUR: On February 25, 1986, at or about 7 :30 a.m. , Kimberly Dawn Chittock, a pedestrian, was struck by an automobile driven by claimant while Kimberly Dawn Chitock was crossing Pacheco Boulevard at a point approximately 152 feet West of De Normandie Way. The accident in which Kimberly Dawn Chittock was injured was a direct and proximate result of the negligence of Contra Costa County, its agents and employees, who while acting within the course and scope of their agency and employment on behalf of said governmental entity, created, designed, constructed, maintained and failed to warn of a dangerous and defective condition on public property, to wit : the location and surrounding area of public roadway where Kimberly Dawn Chittock was injured. Said dangerous and defective condition was not corrected within a reasonable time after said governmental entity, its agents and employees received actual and/or constructive notice of said dangerous and defective condition. DESCRIBE DAMAGE OR INJURY: Major head injury, brain damage, broken leg, pain and suffering, emotional distress, medical and related expenses, loss of future earning capacity. Kimberly J. Chittock , by RECEIVED �qff SA 4- �A Dkfte and through her guardian ad litem, Wesley J. Chittock , Juanita L. Chittock and Wesley J. Chittock have brought suit against defendant and claimant herein, Martha Alexandria Gonzalez, for her injuries. Should claimant herein be caused to pay any amounts to plaintiffs for any damages arising out of this accident, Claimant seeks complete indemnity from Contra Costa County. Claimant was served with such complaint on January 12, 1987 . NAME OF PUBLIC EMPLOYEE(S) CAUSING INJURY OR DAMAGE: Unknown. AMOUNT OF CLAIM: Equitable indemnity and comparative fault. ITEMIZATION OF CLAIM: Special Damages: General Damages : Dated: � U1 ROPERS, MAJESKI , KOHN, BENTLEY, WAGNER & KANE By Dexter B. Louie Attorneys for Claimant MARTHA ALEXANDRIA GONZALEZ i AMEYDED / — CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT April 21 , 1987 and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: $25, 000- 00 Section 913 and 915.4. Please note all "Warnings". CLAIMANT: LEONA A. BREITBARTH C°4"7ty G,o 1066 Laurel Drive Uns ATTORNEY: Lafayette, CA 94549 ApR,1 @� Date received �a 'J 19 (91>ADDRESS: BY DELIVERY TO CLERK ON April 3) T696 BY MAIL POSTMARKED: April 2, 1987 WJ I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. EVIL BATCHELOR, Clerk DATED: April 13 , 1987 B�: Deputy L. Hall II, FROM: County Counsel TO: Clerk of the Board of Supervisors (x) This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: BYj�-"_.&_____e_D�puty County Counsel III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present A$fHNEA10�A (x This Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board' Order entered in its minutes for this date. Dated: APR 2 1 1987 PHIL BATCHELOR, Clerk, By , Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: APR .2 2 1981 BY: PHIL BATCHELOR by eputy Clerk CC: County Counsel County Administrator r.LATM ,TO: BOARD 'OF SUPERVISORS OF CONTRA CO**A Wapp11catbn to: ` Instructions to ClaimantC!erk of the Board M mine California 94553 A: Claims relating to causes of action for death or for 'injury to person or to personal property or growing crops must be presented not later than the 100th day after the accrual of the cause of action. Claims relating to any other cause of action must be presented not later than one year after the accrual of the -cause of action. - (Sec. 911.2, Govt. Code) B. - Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street, Martinez, California 94553. C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. . E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at end of this form. RE: Cl im by or Clerk's filing stamps RECEIVED Against the COUNTY OF CONTRA COSTA) ' '- APR 1987 or DISTRICT) (Filln name ))Reser " 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: -- ------ -------- —s------------------------- --e--- — ..-- ---- 1. When did the damage or in3ury occur? (Give exact date ana riourj 98�. � s• s;aoPrn. '�:- W�iere did the damage or �n3ty] 3. How did the damage or in3ury occuextra sheets if required) e41A..0 � ea� _-I— X3 f�� 3, a-Lt— .d �o c�-ea/-s✓ 'G"''�.t'`! -moi�`"P a1 . -*%.0 aL-+-�-�[�ir`o 4. What particular act or omission on the part of county or dl EER officers, servants or employees caused the injury or damage? (over) •5. What •are the names of county or district officers, servants or' employees causing the damage or/ injury? o 6. WSat damage or injuries do you claim resulted? ZG�ve dull extent ofinjuries or damages claimed. Attach o estimates 4for auto damage � - ----- ----- -- ---- ----------- ....... - -- ----- -- - "7. How was the amount claimed above computed? (Include the est to ?, amount of any pr spe�tiye injurylor damage. ) Q�t„r�-�••��i.�e�a_.e.�-e2.w-i-�-�-� ��.Q�.-:-�,�-c..e dC.c�ai .��sJ ac.�.�.�� � 8� es and addresses of w'tnesses, doctors and o$ rt , �iti , /oZ0 av�. 2/.�:i; c�1ae.•u.�.�'�.kra-+�, , J O —— —tA - Govt. --—————————T—————------------------------——T----—T-------- —T—--— �S. Llsmade on account of this accident or Injury: �•j t P H DRQ ITEM AMOUNT Code Sec. 910.2 provides: "The claim signed by the claimant SEND NOTICES TO: (Attorney) or by some person on his behalf. " Name and Address of Attorney � • Claimant's Signature / Q io oSo=� - - Address -�°,-�!�-.�'t=". Com-,¢• 9�.s"�� Telephone No. Telephone No. C#/5� RRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRR* NOTICE Section 72 of the Penal Code provides: "Every person who, with intent to defraud, presents for allowance or for payment to any state board or officer, '.or to any county, town, city district, ward or village board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account, voucher, or writing, is guilty of a felony. " CLAIM.TO: BOARD OF SUPERVISORS OF CONTRA COQ*r MppJIc9ion to: a 37 Instructions to Claimant0erk of the Board Mninez Califomta94553 A. Claims relating to causes of action for death or for Injury to i� person or to personal property or growing crops must be presented not later than the 100th day after the accrual of the cause of action. Claims relating to any other cause of action must be presented not later than one year after the accrual of the -cause of action. (Sec. 911.2, Govt. Code) -B. Claims must be filed with the Clerk of the Board of Supervisors . at its office in Room 106, County Administration Building, 651 Pine Street, Martinez, California 94553. C.° If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. _ E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at and of this form. RE: Claim by )Reserved for Clerk'astamps - -J ) RECEIVEI D ) Against the COUNTY OF CONTRA COSTA) + eAT On or (FilF in 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: ------------------------ --------------------------------- - --- ---- �. When did the damage or injury occur? (Give exact date ani �iourf 1. ere did tFie damage or injury occur? �Inc�ude city and county] M 3. How did the damage or in3ury 0-ur? ( 've uII"de.talS-s, use extra sheets if required) , 4. What art�cult or omission on the part of county district officers, servants or employees caused the injury or damage? (over) S.- -What are the names of county or district officers, servants or, employees causing the damage or injury? F. -RUE damage or 1 3 1 do you claim resui-ted'? ZGive fuii-extent of injuries or damages claimed. Attach two estimates for auto damage) ,er/ 3 _ -v, � - - ?1R2.� - ----- ------� - - �e_d_? Xllii - ---- -- ; 7. How w st.he amo t claiRe4aabode compulude the estimated . amount of any �osp�e�ctivenjury or damage. ) o0�-t, �4. -.L- ' ,�'i •v6',(�'�x-) . ------------- 8. Names and addresses of witnesses, doctors and hospitals. 4---- ---------------- �S. Li you made on account of this accident or injury: � . S ITEM AMOUNT riy' 'rY . pi.�aJ `• .tri �6'. •� L f:c� i°-�i�B . v Govt. Code Sec. 910.2 provides: "The claim signed by the claimant SEND NOTICES TO: (Attorney) or by some person on his behalf. " Name and Address of Attorney Claimant's Signature Address Teleohone No. Telephone No. -- -- NOTICE Section 72 of the Penal Code provides: "Every person who, with intent to defraud, presents for "allowance or for payment to any state board or officer, •.or to any county, town, city district, ward or village board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account, voucher, or writing, is guilty of a felony. " APPLICATION TO FILE LATE CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COMM, CALIFORNIA BOARD ACTION Application to File Late Claim ) NOTICE TO APPLICANT April 21, 1987 Against the County, Routing ) The copy of this document mailed to you is your Endorsements, and Board Action.) notice of the action taken on your application by (All Section References are to ) the Board of Supervisors (Paragraph III, below), California Government Code.) ) given pursuant to Government Code Sections 911.8 and 915.4. Please note the "WARNING" below. Claimant: JULIA MARTINEZ County Counsel 1657 Kingsly Drive Attorney: Pittsburg, CA 94565 MAR,19 1987 Address: Martinez, CA 94553 Amount: Unspecified By delivery to Clerk on March 13 , 1987 Date Received: March 13 , 1987. By mail, postmarked on March 12 , 19.87 I. FROM: Clerk of the Board of Supervisors 70: County Counsel Attached is a copy of the above noted Application o F 7te Claim. DATED: March 17 , 19.87 PHIL BATCHELOR, Clerk, By Deputy L. Hall II. FROM: County Counsel T0: Clerk of the Board of Supervisors ( ) The Board should grant this Application to File Late Claim (Section 911.6). The Board should deny this Application to File Late Claim (Section 911.6). DATED: VICTOR WESTMAN, County Counsel, ���G s9�pt�ty III. BOARD ORDER By unanimous vote of Supervisors present (Check one only) ( '�) This Application is granted (Section 911.6). ()() This Application to File Late Claim is denied (Section 911.6). I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Ile APR 21 1987 DATE: Deputy PHIL BATCHELOR, Clerk, By � _ WARNING (Gov. Code 3911.8) If you Wish to file a court action on this matter, you must first petition the appropriate court for an order relieving you from the provisions of Government Code Section 945.4 (claims presentation requirement). See Government Code Section 946.6. Such petition must be filed With the court Within six (6) months from the date your application for leave to present a late claim Was denied. You may seek the advise of any attorney of your choice in connection With this matter. If you Want to consult an attorney, u should do so immediately. IV. FROM: Clerk of the Board T0: 1 County Counsel 2 County Administrator Attached are copies of the above Application. We notified the applicant of the Board's action on this Application by mailing a copy of this document,. and a memo thereof_ has ben filed and endorsed on the Board's copy of this Claim in accordance with Section 29703• APR 2 2 1987 DATED: PHIL BATCHELOR, Clerk, By Deputy V. FROM: 1 County Counsel 2 County Administrator TO: Clerk of the Board of Supervisors Received copies of this Application and Board Order. DATED: County Counsel, By County Administrator, By APPLICATION TO FILE LATE CLAIM , 1 The Board of Supervisors mrd t CWk«g. Costa °� County AdmirlistrStion Building � oµsi P.O. Boz 911 / Martinez, Cefifornia 94553 "' "J Tam re"ts.tat OKmct MhC7 C rahem VW Qstnct AWA I scowed ►,*0 Q�athCt w"h,WHOM mc/rt,4th oot"Ct TMS Toesksm.SM pKtntt EVE. REC Ml��' t14 TO: Julia Martinez P Ft 1657 Kingsly Drive Pittsburg, CA 94565 111 MCE TO CLkv44PT!' Late—Film) (Goverrnmt Code Section 9]1.3) 01 7he claim you presented to the Board of Supervisors of Contra Costa County, California, as governing body of the x _ County of Contra Costa and/or District, • ;.:. February 4 is ieitx� returned t you herewith because it was not present v thin 100 days after the evert or cocurrenoe as required by law. (See Sections 901 and 911.2 of the Government Code.) Because the claim was not presented within the time allowed by law, no action was taken an the claim. Your only recourse at this time is to apply without delay •. to the Board of Supervisors (in its capacity noted above) for leave to present a late claim. (See Sections 911.4 to 912.28, Inclusive,, and Section 946.6 of the Goverment Lode.) ander owe circumstances, leave to present a late claim will be granted. (See Section 911.6 of the Goverment Lode.) You may seek the advice of an attorney of yaa choice in connection with this matter. if you desire to consult an attor- ney, you should do so Immediately. '10 W PIUEZ IN BY WE CUM CF W= GMY IF AP'Pl. CNKZ: ( ) Binoe a portion of your claim is not untimely,, we are retaining a Dopy of your claim for Board action on that portion of your claito which is not untimely. Phd Batchelor, Clerk of the Board of Supervisors and County Admiwwatcr ��, • , Deputy Clerk Date: February 24 19.87 1. IZ " ���� %��✓'/�G ""`''�6��=-''/L-Z'� 1-7 Patr � 17; � ,,,fes+ •! ,F(r/ ;� O�" 1 ��,r �Y'j�_ � . � S r L, �L4 IL , - � AS JAS t \� c t -r .� ACK 1