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HomeMy WebLinkAboutMINUTES - 06131995 - 1.12 CLAIM I, ' BOARD OF SUPERVISOR$ OF CONTRA COSTA COUNTY, CALIFORNIA �-Jr une__13:,_:I99=5D Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to ) The copy of this document mailed to you is your 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: $2,613.40 tion 913 and 915.4. Please note all "Warnings". CLAIMANT: Frank Benissa , 3A Insurance MAY 2 5 1995 ATTORNEY: COUNTY COUNSEL MARTINEZ CALIF. ? c/o Deanna Hend ? Date received ADDRESS: 2055 Meridian Park Blvd BY DELIVERY TO CLERK ON May 24, 1995 Concord, CA 94520 BY MAIL POSTMARKED: Hand Delivered I. FROM: Clerk of the Board. of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. ppHH DATED: May 25, 1995 BYIL BATCHELOReputX , Clerk r 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: t G� Dated: BY: Deputy County Counsel III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present ( V ) 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: PHIL BATCHELOR, Clerk, By, 1 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. * For Additional Warning See Reverse Side Of This Notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: k. ,- � �����4 BY: PHIL BATCHELOR by� Deputy Clerk CC: County Counsel County Administrator Cla-;- to: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIRANT A. Claims relating to causes of action for death or for injury to person or to per- sonal property or growing crops and which accrue on or before December 31, 1987, must be presented not later than the 100th day after the accrual of the cause of action. Claims relating to causes of action for-death or for injury to person or to personal property or growing crops and which accrue on or after January 1, 1988, must be presented not later than six months after the accrual of the cause of action. Claims relating to any other cause of action must be presented not later than one year after the accrual of the cause of action. (Govt. Code 5911.2.) B. Claims must be filed With the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street, Martinez, CA 94553. C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. E. Fraud. See penalty for fraudulent claims, Penal. Code Sec. 72 at the end of this form RE: Claim By / ) Reserved for Clerk's filing stamp RECEIVE® Againstthe he County of t;ontra Costa ) hwd Adiv 'G , J or ) MAY 2 4 1995 District) CLERK BOARD OF SUPERVISORS Fill in name ) CONTRA COSTA CO. The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District in the sum of $ J(o l r `/d and in support of this claim represents as follows: 1. When did the damage or injury occur? '(Give exact date and hour) _.�.�L.-23=.. --..�1 .�.� m 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 paper if required) We 4. What particular act or omission on the part of county or district officers, servants or employees caused the injury or damage? Te rd,,-,(-, 44 4-lv,-e TO /-)Le r-►fAT 0 y ;cv�r> �. wnat are the names of county or district officers, servants or employees causing the -`a:-�age or injury*? ----------------------------------------------------------- 5. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage. 7• How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) 3. Names and addresses of witnesses, doctors and hospitals. - - ----------�_.� 9. List the expenditures you made on account of this accident or injury: DATE ITEM AMOUNT -7,4�r3 . esTi ���y�3 , yb -t71-Se. re,-f a C,-r- . �/S't� _ a-c> i iF * � fE !F 1F 1F iE -�F:•'.9E �F '�F '#��9t1F 9F �F -�F �F.� !F �F �F IF �F � � �F 9F �F �F �F 9F �F !t * iE iF !F IF it Gov. Code Sec. 910:2 provides: "The claim must be signed by the claimant SEND NOTICES TO: (Attorney) or by someperson on his behalf." Name and Address of Attorney Claimant's Signature 2 d-5:S� 422-e, ' IJJ wn Address Telephone No. Telephone No Llo ( /` 7 .33( NOTICE Section 72 of the Penal Code provides: - - "Every person who, with intent to defraud, presents for allowance or for paymeIt, to any state board or officer, or to any county, city or district board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account, voucher, or writing, is punishable either by imprisonment in the county jail for a period of not more than one year, by a fine of not exceeding one thousand ($1,000), or by both such imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ($10,000, or by both such imprisonment and fine. 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'�"- .- t"��fl n� '� Ft :sem`ri."<, x M. i -a�+"r N.1�1V-& w x A' "" ;` Y.rzv -C y�,� L-, sh- A.S.w".2 ns Y -_`Ia, ® L�:,,$ Q �' n-y #:s xa�g .-r.c¢," .'.i`Q'` ,,.,`r k-rr.< S4 JJ1'E�.rN. I T '�4' n 'F-c r 1 1 .hY` mar, �,� _O5r a �E O x O Oma• *cc A ?'' ^, d`" :. a 3 s ;' ,a a q �-f-,e Ali S� a x}.,—1 t".�-­--��`�j-L . __ -- -."..t- ."L...,.-:.,. .,,� .�--.-,,..-.,,. j.;.,. :, I'll"�wla,!+.. �`�,,,4rae� Y�+r -,�..�",�,x,��.:'xk. �' 5 't` zt #'•^�, at. T - .. _.- . -. . . ,r, „ , _ -. ,:. ,: .. .,.:_, ENTERPRISE INVOICERENTAL _ -� IiIT—A—CAR a • X 036810 1260 DIAMOND WAY :` DESCRIPTION RATE AMOUNT CONCORD CA 94520-5226 .BAR U � T!5. Received .. 24 DAYS @ 24 . 00 576, 0D FED TAX ID# 36-3041733- BILLING INQUIRIES CALL 510-674-1110 AAA INS-CONCORD . . P. 0. BOX 4019 BILL CONCORD CA 94524 TO DATE OUT GATE IN - 11/29/94 12/23/94 RENTER HOMEPHONE FRANK BENICASA 510-682-1846 24 DAYS DW- @ 8 . 99 215.76 ADDRESS OFFICE PHONE 240 SANDY COVE LN 510-689-8921 24 DAYS PAI @ 1 .00 24. 00 CITY STATE ZIP PITTSBURG CA 94565 SALES TAX% 8.25 47. 52 DRIVER'S LICENSE STATE I EXPIRES Y0302277 CA 5/20/95 DOB HEIGHT WEIGHT SOCIAL SECURITY 8 5/20/15 5 11 185 ON FILE. .. X"TER SIGNATURE ON FILE TOTAL CHARGES. 863. 28 REQUEST FOR PERMISSION FOR PERSON OTHER THyN RENTER TO DRIVE. NAME NO OTHERS bouncer 1 _.' LESS AMOUNT RECEIVED .00 AGE LICENSE NO. STATE EXP L - N� 2� CHARGED TO OTHERS 713. 28 • 150 .00 't 'YRENTAL,VEHICLES ` � k CLAIMaWFORMATION ,. ,r' 4 ?h.r I BUSINESS ' $� .,a.., ,."'t,.,Y .;✓s .. -`.w nc�.M� x-e1..,.a. tz,x-?„ta..,m..a,rr ,z.,m,. r A �^- 01 y'F0rRi, .� U $'#3 +L.tst, d -tb 3 n v fin, ✓ TE1J500 cLAIULCi3 tpf88 TDA` CIER e;0351 I"S` NICASA ° t �� ��`" .,".r'.''""''. �s e5':'mss .t s ,'y,'"'�"` 'ati y COLOR LICENSE NO. 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Estimate ID: 749 Supplement: 001 (F) 12/22/94 06:30 A.M. r� Profile ID: Mitchell Standard _ M & T AUTO BODY 2291 VIA DE MERCADOS CONCORD CA 94520 (510) 685-2294 Damage Assessed By: Rick Torres Appraised For: CSAA Concord 3�Sy85 D YJU Supplemented By: Rick Torres Claim Number: 02-E85488=MIKE MANNIE Insured: FRANK BENICASA Address: 3330 CONCORD WY CONCORD CA 94520 Home Phone: (510) 682-184L Mitchell Service: 918472 Description: 1986 OLDSMOSILE/CUTLASS/SUPREME/4DR/SDN, VIN: 1G3GR69Y9GR3889 Mileage: 98,463 OEM/ALT: 0 Line Entry Labor Line Item Part Type/ Dollar Labor Item Number Type Operation Description Part Number Amount Unit 1 900500 BODY *REMOVE/REPLACE *FRONT END CMPLETE-USED/C.AUTO DISM. QUAL RECYCLED PART 600.00* 8.0* 2 REFIN REFINISH/REPAIR FRONT END CMPLETE-USED/C.AUTO DISM. 5.2* 3 804440 BODY REPAIR *HOOD PANEL 1.5*# 4 AUTO REFIN REFINISH HOOD OUTSIDE 3.1 5 805080 BODY REPAIR *COOLING RADIATOR SUPPORT 2.0*# 6 807690 BODY REPAIR *L FENDER PANEL 1.0*# 7 AUTO REFIN REFINISH L FENDER OUTSIDE 2.0 S 8 809180 FRAME REPAIR *FRT FRAME MEMBER ASSEMBLY 2.5*# S 9 REFIN REFINISH/REPAIR FRT FRAME MEMBER ASSEMBLY 0.5* S 10 900500 BODY*ADD'L LABOR OPR*CLEAN UP USED PARTS EXISTING 1.0* S 11 900500 BODY *ADD'L LABOR OPR*RE-DRILL HOLES USED PARTS,MLDGS. EXISTING 1.0* 12 819120 REFIN BLEND R FRT DOOR OUTSIDE 1.2 13 900500 FRAME*ADD'L LABOR OPR*PULL& SQUARE FRONT END EXISTING 2.0* 14 933002 REFIN ADD'L LABOR OPR CLEAR COAT 1.3* 15 933003 REFIN ADD'L LABOR OPR TINT COLOR 16 933006 FRAME ADD'L LABOR OPR FRAME/RACK SET UP 1.0* 17 933018 REFIN ADD'L LABOR OPR MASK FOR OVERSPRAY 18 936008 ADDIL COST PAINT/MATERIALS 199.08* * Judgement Item # Labor Note Applies Remarks :SAA ADJUSTER MUST AUTHORIZE ANY ANDALL REPAIRS.DUE TO EXTENT OF )AMAGE AND YEAR OF VEHICLE,CSAA ADJUSTER TO INSPECT AND INFORM 30DYSHOP ON INSTRUCTIONS. ESTIMATE RECALL NUMBER: 12/06/94 07:40:52 749 Mitchell Data Version: DEC_94_A Copyright (C) 1990, Mitchell International Page 1 of 2 All Rights Reserved Date: 12/22/94 06:30 A.M. Estimate ID: 749 Supplement: 001 (F) 12/22/94 06:30 A.M. Profile ID: Mitchell Standard I. Labor Subtotals Units Rate Totals 1`-��� II. Part Replacement Summary Amount . Body 14.5 48.00 696.00 1 Taxable Parts 600.00 Refinish 13.3 48.00 638.40 Sales Tax @ 8.25% 49.50 Frame 5.5 48.00 264.00 Total Replacement Parts Amount: 649.50 Labor Subtotal 1,598.40 Labor Summary Totals 33.3 1,598.40 I11. Additional Costs Amount 1. Total Labor: 1,598.40 Taxable Costs 199.08 11. Total Replacement Parts: 649.50 Sales Tax is 8.25% 16.42 III. Total Additional Costs: 215.50 Total Additional Costs: 215.50 Gross Total: 2,463.40 Customer Allowance: 0.00 Customer Responsibility: 0.00 Net Total: 2,463. / Less Previous Net Total: Net Supplement Amount: 240.00 VIN is unable to decode. l ESTIMATE RECALL NUMBER: 12/06/94 07:40:52 749 Mitchell Data Version: DEC 94—A Copyright (C) 1990, Mitchell International Page 2 of 2 All Rights Reserved ImageMate a� 'MEFF# : V2385488 Page :Claim# : Name : ASA Slide l : 749 O .EST Date: 12/06/94 07:40 A.M. Estimate ID: 749 Committed Profile ID: Mitchell Standard �/ l' M i T AUTO BODY •/ //" 2291 VIA DE M $ CONCORD CA 99520 - (510)510) 685-2294 Damage Assessed By: Rick Torres Appraised For: CSAA Concord Claim Number: 02-E85488-MIXE MANNIE Insured: PRANK BENICASA Address: 3330 CONCORD WY CONCORD CA 94520 Home Phone: (510) 682-1846 Mitchell Service: 938472 Description: 1986 OLDSMOBILE/CUTIASS/SUPREME/4DR/SDN ; %• VIN: 1G3GR69Y9GR3889 Mileage: 98,463 OEH/ALT: 0 LineEntry Labor Line Item Part Type/ Dollar Labor Item Number Type Operation Description Part Number Amount Unit 1900500 BODY'REMOVE/REPLACE -FRONT END CMPLETE-USED/C.AUTO DISH. QUAL RECYCLED PART 600.00• 8.0• 2 REFIN REFINISH/REPAIR FRONT END CMPLETE-USED/C.AUTO DISH. 5.2• 3 804440 BODY REPAIR ..OD PANEL 1.5.4 4 AUTO REFIN REFINISH MOOD OUTSIDE 3.1 5 805080 BODY REPAIR •COOLING RADIATOR SUPPORT 2.0.4 6 807690 BODY REPAIR 'L FENDER PANEL _ 10•i 7 AUTO AS IN REFINISH L FENDER OUTSIDE 2..0 B 619120 REFIN BLEND A FRT DOOR OUTSIDE 1.2 9 900500 FRAME•ADD• RE L LABOR OPR•PULL4 SQUARE FRONT END EXISTING 2.0' SO 933002 REFIN ADD•L LABOR OPR CLEAR COAT II 11 933003 REFIN ADD'L LABOR OPR TINT COL0R 12 933006 FRAME ADD•L LABOR OPR FRAME/RACK SET UP 1.0• 13 933018'REFIN ADD'L LABOR OPR MASK FOR OVERSPRAY 14 936008 ADD-L COST PAINT/MATERIALS 199.08` • Judgement Item 1 Labor Note Applies ' Remarks CSAA ADJUSTER MUST AUTHORIZE ANY ANDALL REPAIRS.DUE TO EXTENT OF DAMAGE AND YEAR OF VEHICLE,CSAR ADJUSTER TO INSPECT AND INFORM BODYSHOP ON INSTRUCTIONS. . I. Labor Subtotals Units Aate Totals II. Part Replacement summary Amount Body 12.5 48.00 600.00 Taxable Parts 600.00 Refinish 12.8 48.00 619.40 Sales Tax @ 8.254 49.50 Frame 3.0 98.00 194.00 Total Replacement Parts Amount: 649.50 Labor Subtotal 1,358.40 Labor Summary Totals 28.3 1,358.40 ESTIMATE RECALL NUMBER: 12/06/94 07:40:52 749 Hi tchell Data Version: DEC 94_A Copyright (CJ 3990, Mitchell International - Page 1 of 2P - All Rights Reserved Date: 12/06/94 07:40 A.M. Estimate ID: 749 Committed Profile ID: Mitchell Standard III. Additional Coats Amount I. Total Labor; 1,358.40 Taxable Coats 199.08 II. Total Replacement Parts: 649.50 Sales Tax @ 8.258 16.42 III. Total Additional Coats: 215.50 Total Additional Costs: 215.50 Gross Total: 2,223.90 Customer Allovance: 0.00 Customer Responsibility: 0.00 Net Total: 2,223.40 VIN is Unable to decode. '% i_��• l ESTIMATE RECALL NUMBER: 12/06/94 07:40:52 749 I ImageMate .MEFF#: 11506 Page: 1 Claim#: 02-E385488 Name: BENICASA - 2: 3: 4: -tea. '• 5: ■ ■ •• -• }::•_.,. \' s_�,:: 1i2. 4•,w. t „��"�;�c a fig"', '�• � ^:r .�1� .: ;` .rte;. • • � . • r ■ . • 77 �• i ter► _ P` u i` ;�,, �. .. V 7-J, Ck �S • {,, ilk r _ • ■ • , � �`.; � �� ..ref , CLAIM I BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA June -13, 19950 Claim Against the County, or District governed bY) BOARD ACTION the c,zrd of S❑pervisors, Routing Endorsements, ) NOTICE TO CLAIMANT 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 D ar'raph IV below), given pursuant to Government Code Amount: Unknown c 913 and 915.4. Please note all "Warnings". CLAIMANT: Loretta Louis Fallis MAY 2 5 1995 COUNTY COUNSEL ATTORNEY: Jeffrey R. Siegel, Esq. MARTINEZ CALIF. Date received ADDRESS: 2817 Crow Canyon Rd. ; Ste. 203 BY DELIVERY TO CLERK ON May 23, 1995 San Ramon, CA. 94583 BY MAIL POSTMARKED: May 22, 1995 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. pH BATCHELOR, � DATED: May 25, 1995 BYIL BATCepuHELOR, Clerk 11. FROM: County Counsel TO: Clerk of the Board of Supervisors ( his claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: / BY: Deputy County Counsel 111. FRC.M: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. B NaR: = ER: By unanimous vote of the Supervisors present (✓) T!is Claim is rejected in full. ( ) '0trer: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: Jq r 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 I*:ay seek tre BtO ce cf an attorney of your choice in connection with this matter. If you want to consult an attcr-.e,, y:u st�c­1d do s: immediately, For Additional j;arnino See Reverse Side Of This Notice. AFFIDAVIT OF MAILING 1 de:lore under penalty of perjury that 1 am now, arc at all times herein mentioned, have been a citizen of the United S:a:es, over ace 1=; and that today I dE.?OSited in the United States Postal Service in Martinez, Ca1 •f.-nip, postage fully prepaid a ce-:if'ed :coy of this Board Order and Notice to Claimant, addressed to re cl.a=mant a$ shown at:ve. -o:cJLA A^ 14 .) l_ BY: PHIL EA?C!'E_OR .ty Deputy Clerk --. .c .^ty CC 'i County Administrator LAW OFFICE OF JEFFREY R. SIEGEL JEFFREY R. SIEGEL, ESQ. S.S.#112061 RECEIVED 2817 Crow Canyon Road, Suite 203 R ECE . CE San Ramon, CA 94583 Telephone: (510) 820-7655 MAY 2 31995 Fax: (510) 820-7656 Attorneys for Claimant CLERK CO TRDOCOSTA CO.SOBS C L A I M PUBLIC ENTITY: County of Contra Costa 1. Name and Address of Claimant: Loretta Louis Fallis 1421 Springbrook Road Walnut Creek, CA 94596 2. All notices should be sent to: Jeffrey R. Siegel, Esq. LAW OFFICE OF JEFFREY R. SIEGEL 2817 Crow Canyon Road Suite 203 San Ramon, CA 94583 (510) 274-9800 3. The date, place and other circumstances of the occurrence or transaction which gave rise to this Claim are as follows: . On March 3, 1995, claimant was traveling south on Springbrook Road at approximately 25 MPH. Claimant attempted to avoid an unmarked hole when the left driver's rear tire cut the edge of the hole and slid into the deep trench. Claimant sustained injuries to her head, neck, shoulder and right arm and hand due to said impact. GOVERNMENTAL ENTITY CLAIM PAGE -2- 4. A general description of the indebtedness, obligation, injury, damage or loss incurred so far as it may be known at the time of presentation of the Claim it as follows: Personal injuries. 5. The name and names of the public employee or employees causing the injury, damage, or loss, if known are as follows: EBMUD employees, names unknown. 6. The amount claimed as, of the date of presentation of this Claim, including the estimated amount of any prospective injury, damage, or loss, insofar as it may be known at the time of the presentation of this Claim, together with the basis of computation of the amount claimed is as follows: Superior Court. DATED: LAW OFFICE OF JEFFREY R. SIEGEL By: •JEF Y R. I GEL Att rney o laimant r cis o Ul o d� f e�`• QN ,ytrs td U 00 un CO tk N a• s o- W °� ao cI% o G . v V o H a.. 5% Jeffrey R. Siegel RECEIVE® Attorney.at Law MAz 3 1995 2817 Crow Canyon Road MAY Suite 203 San Ramon, California 94583 CLERK BOAR)OF SUPERVISORS 510-820-7655 CONTRA COSTA CO. FAX: 510-820-.7656 VIA CER1IFIED/RET1JRN RECEIPT REQUESTED FIRST CLASS U.S. POST May 22, 1995 County of Contra Costa Board of Supervisors 651 Pine Street Martinez, CA 94.553. Dear Sir/Madame: Enclosed herewith is an Claim and one copy. Please mark the copy received and return to this office in the envelope provided. Thank you very much. Very truly yours, LAW OFFICE OF JEFFREY R. SIEGEL Patricia A. Twist Secretary to JEFFREY R. SIEGEL ENCLOSURES Apt M COUNTY.1 - - CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA - �• I 2� • ' - `June 13, 1995, Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to ) The copy of this document mailed to you is your 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: $55000.00 + Section 913 and 915.4. Please note CLAIMANT: Michelle Gutierrez, Maria Gutierrez, Emmanuel Dummpit, parents of Michelle Gutierrez MAY 19QJ ATTORNEY: Steven R. Clawson COUNTY COUNSSL Date received MARTINE,ZCALIF. ADDRESS: 1710 Pennsylvania Avenue, Suite C BY DELIVERY TO CLERK ON May 18, 1995 Fairfield, CA 94533 BY MAIL POSTMARKED: May 16, 1995 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. ��IL BATCHELOR, Clerk ' DATED: May 18, 1995 : Deputy I1. FROM: County Counsel TO: Clerk of the Board of Supervisors (v< This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: BY: Deputy County Counsel 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 ( v ) 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: 13_ 1996 PHIL BATCHELOR, Clerk, By 1aoDeputy 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. * For Additional Warning See Reverse Side Of This ?notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 16; 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:- BY:c� 9 �js _ BY: PHIL BATCHELOR b lip Deputy Clerk CC: County Counsel County Administrator C� rr :a tjl K1 0 C� Z � ➢ r �, c v ➢a� cs SJ w 't3 O N � W ol Ila tf' N C7 �' C✓, •"`�:` Q�p � ICS r' t/ q 1e' � QdQ�Qa{r dr �tl t 0 I TO: BO;D OF SO RPISCRS a' CGb2TRAc0§ �"' ppltcation : Ihstructions to C1ai4_.ttCleh`of the Board Martin=Catffotnta 94553 A. Clain relating to causes of action for degth or for fn�=y to person or to personal property o: groxing crops mus be "presented not later than the 100th day afte_• 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 Admimistrati.on Building, 651 Pine Street, Martinez, California 94553. c. If claim is agzinst a district governed by the Board of Supervisors, rathez than the Cou=zy, the name of the District should be filled in. D. xf the lain-% is ag ;,,st more- than one Public entity, -separate claims must .be f iled against each pudic entity. E. Fraud. See "penalty for fraudulent claims,, Peel Code See. 72 at and OF—thisfo m. tt�estttr*t:fr,tt�:ettttttt*t*x*,retrtett+ttsrt�t*tt**t*t�trt*ttttt**r*t*,car**t* .R.:: Claim by )Reserved for Clerk' s filing stamps Michelle Gutierrez, Maria Gutierrez, F:mmarn](A 11r=i t, parents of Michelle --- Gutierrez ) RECEIVED } Against, the COUNTY OF CONTRA COSTA) 10 _ or VISTRSCT) CLERKg0A pp SUPERVISORS (Fillin name ) CONTRA COSTA CO. The undersigned claiment hereby makes claim against the County of Contra Costa or the above-named District in the sum o $ and in support o! this claim represents as follows: 1. FIhen did the-damage or inju:=y occur? (Give exact dEte Dna hour) - November 21, 1994 .::fx -pv. --- --- - Z. -Whe:.e did 'the damage or :-nt=y oCat? (Include cit. an county) Infant Center Greater Richmond Social Services Corporation ! 1310-1350 Bissell Avenue, Richmond, California 94801 -,- ----_��-- ----..- .- .----------------------- ►-r---- ------------- 3. Sow did the damage or injury oc� s ? (Give fes_! details,, use extra sheets if required) See Attachment A --r....-- �—M—M T�--r—..—.�� 4. What par ri :lar act o_ omission on the par: of caun:.y o_ distric: officers , se_v-ants or employees caused the =3=-y or damage? See Attachment. A (over) S. What are the nam ' of county or district of ens, servants or empioyees causing the damage ar injury? Ms. Bradshaw, Clyde Wilson; Ralph W. Emerson, President, Infant Center of the Greater Richmond Social SErviee Corporation, Greater Richmond Social Services Corporation 67--Wha7 damage or injuries do yon claim result..ed?+(dive full extent of injuries or damages claimed. Attach two estimates for auto damage) Scalding water to the left side face, head, neck and shoulder; scarring, disfigurement and hypopigmentation to the left side. face, head, neck and shoulder. 7. How was the amount claimed above computed? (Includee the estimated amount of any prospective injury or damage. ) Jurisdiction rests in the Superior Court 8. Names and addresses of witnesses, doctors and hospitals. Kaiser Permanente Angelo Capozzi, M.D. Ronald M. Sato, M.D. 901 Nevin Avenue 1710 Pennsylvania AVE. 2000`.Vale Road Richmond, CA 94801 Fairfield, CA 94533 San Pablo, CA 94806 ---�.-�..�----- -^'rte----.���.--.�.-�---- .. .r.� .�.-� -- ---� ----� .. 9. List the expenditures you made on account of-th�is-acc2dent- - or in--3ury: DATE ZTE14 AMOUNT Medical treatment is continuing. Medical expenses in excess of $5,000.00. Gov`. Code Sec. 910.2 provides: "The claim signed by the claimant SEND NOTICES TO: (Attorney) or by "some person on his ehelf . " 'Name and Address of Attorney _ STEVEN R. CLAWSON 0 C a=an signature WELLS, CALL, CLARK & BENNETI' 1710 Pennsylvania Avenue, Suite C 1710 Pennsylvania Avenue, Suite C Address Fairfield, CA 94533 Fairfield, CA 94533 Telephone No. (707) 426-5300 Telephone No. (707) 426-5300 esrtr#ter*eee:s+eessx**ttxue*eee�rs::stt#R#*###�r#rrf�r###,t#**+r.t*#w#�tt#*t*#�#* 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, wa=d 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. " Attachment A This claim is based on injuries and damages sustained by claimants as a result of the injury to claimant, Michelle Gutierrez, the daughter of Maria Gutierrez and Emmanuel Dummpit, and the emotional and economic damages sustained by the parents of Michelle Gutierrez, Maria Gutierrez and Emmanuel Dummpit, also claimants herein, which all arises out of an accident that occurred on November 21, 1994, at the infant center of the Greater Richmond Social Service Corporation, Facility #070209803 at 1310-1350 Bissell Avenue, City of Richmond, State of California. Michelle Gutierrez was a five and one-half month old infant, natural daughter of claimants, Maria Gutierrez and Emmanuel Dummpit, who was placed in day care at the infant center of the Greater Richmond Social Service Corporation, Facility #070209803 at 1310-1350 Bissell Avenue, City of Richmond, State of California, pursuant to placement in that nursery and day care facility by the County of Contra Costa. The care provided to Michelle Gutierrez by the the Greater Richmond Social Service Corporation and the County of Contra Costa, was careless and negligent, and the placement of Michelle Gutierrez, in the day care program, and the supervision and training of the Greater Richmond Social Services Corporation and its employees and faculty was carelessly and negligently performed by the County of Contra Costa, proximately resulting in the injuries alleged herein. The conduct of the County of Contra Costa was additionally careless and negligent and was below the standard of care required of the County of Contra Costa, such to that it constituted the proximate cause-of the physical injuries of Michelle Gutierrez, the emotional injuries of Michelle Gutierrez, and the emotional injuries of the parents of Michelle Gutierrez, Maria Gutierrez and Emmanuel Dummpit, in which negligence and carelessness include, without limitation, the following: (a) The COUNTY OF CONTRA COSTA failed to enforce laws and regulations relative to the care by the Facility of Michelle Gutierrez and failed to take other actions necessary to protect and ensure the proper care of Michelle Gutierrez. (b) The COUNTY OF CONTRA COSTA failed to conduct adequate inspections of the Facility. (c) The COUNTY OF CONTRA COSTA failed to adequately monitor the care and supervision of Michelle Gutierrez provided by the Facility. (d) The COUNTY OF CONTRA COSTA failed to enforce the provisions of the Provider Agreement and/or the Admission Agreement relative to the care of Michelle Gutierrez by the Facility. (e) The COUNTY OF CONTRA COSTA failed to ensure that the facility maintained adequate insurance coverage relative to potential claims with respect to their care of infants, including without limitation, Michelle Gutierrez. (f) The COUNTY OF CONTRA COSTA failed to terminate the placement of Michelle Gutierrez and remove her from the Facility when they knew, or in the exercise of reasonable care should have known, that the Facility was not providing the care required by the infants of the Facility, including without limitation, Michelle Gutierrez and when they knew, or in the exercise of reasonable care should have known, that the Facility was not being operated in accordance with applicable statutes, laws and regulations and below an acceptable standard of care. (g) The COUNTY OF CONTRA COSTA failed to provide or obtain necessary medical care for Michelle Gutierrez when they knew, or in the exercise of reasonable care should have known, that it was necessary. At all times herein mentioned, the County of Contra Costa, including its agents, principals, employees, counsels, departments, divisions and committees carelessly, negligently, recklessly, unlawfully and defectively designed, owned, operated, managed, controlled, inspected, supervised, installed, equipped, modified, maintained, and performed work at the infant center of the Greater Richmond Social Services Corporation, Facility#070209803 at 1310- 1350 Bissell Avenue, City of Richmond, State of California, so as to proximately cause or contribute to the injuries or damages claimed herein. At all times herein mentioned, the County of Contra Costa, including its agents, principals, employees, counsels, departments, divisions and committees carelessly, negligently, recklessly, unlawfully and defectively taught, trained, oversaw, supervised, equipped, managed, and instructed -the infant center.and its employees' of the Greater Richmond Social Services Corporation, Facility #070209803 at 1310-1350 Bissell Avenue, City of Richmond, State of California, so as to proximately cause or contribute to the injuries or damages claimed herein. At all times herein mentioned, the County of Contra Costa, including its agents, principals, employees, counsels, departments, divisions and committees carelessly, negligently, recklessly, unlawfully and defectively failed to safely care for and protect Michelle Gutierrez, other infants, members of the public and visitors of the infant center of the Greater Richmond Social Services. Corporation, Facility #070209803 at 1310-1350 Bissell Avenue, City of Richmond, State of California, so as to proximately cause or contribute to the injuries or damages claimed herein. The above-described negligence and dangerous conditions of the above premises were all in violation of applicable OSHA requirements, Health and Safety Codes and ordinances, or local city and county ordinances, Welfare and Institutions Codes and ordinances, administrative Codes and ordinances, and, state statutes applicable to the safe operation of the day care operations, and supervision management of day care operations of the infant center of the Greater Richmond Social Services Corporation, Facility #070209803 at 1310-1350 Bissell Avenue, City of Richmond, State of California, so as to proximately cause or contribute to the injuries or damages claimed herein. The above said carelessness, negligence, recklessness and unlawfulness of the County of Contra Costa, their failure to provide a safe changing area for infants, and their failure to inspect and supervise, their failure to properly train and instruct the workers of the infant center and supervisors of the infant center, of the Greater Richmond Social Services Corporation, Facility #070209803 at 1310-1350 Bissell Avenue, City of Richmond, State of California, cause that Michelle Gutierrez be changed next to scalding water, which was used to warm baby bottles, and caused the scalding water to be pulled down or tipped over onto the infant, Michelle Gutierrez, causing the injuries alleged herein to the minor, Michelle Gutierrez, and the injuries and damages sustained by the parents of Michelle Gutierrez, Maria Gutierrez and Emmanuel Dummpit, which include, but are not limited to emotional trauma and distress, and all Dillon vs. Legg damages, wage loss, loss of income, and the cost for reasonable home healthcare services that had to be provided to the minor, Michelle Gutierrez, during her convalesces. At all times herein mentioned, the County of Contra Costa, including its agents, principals, employees, counsels, departments, divisions and committees carelessly, negligently, recklessly, unlawfully and defectively failed to immediately inform the parents of Michelle Gutierrez that she had been burned or scalded due to the negligence of the infant center of the Greater Richmond Social Services Corporation, the County of Contra Costa, and it's employees, failed to provide immediate first aid or to provide first aid of any kind, and failed to immediately take the child to the emergency room or obtain medical advice of any kind, which increased the injuries and damages of Michelle Gutierrez, so as to proximately cause or contribute to the injuries or damages claimed herein. I ( WELLS, CALL, CLARK & BENNETT A PROFESSIONAL CORPORATION ATTORNEYS AT LAW E. GORDON WELLS, JR. 1710 PENNSYLVANIA AVENUE, SUITE C DAVIS.OFFICE R. DAYTON CALL FAIRFIELD, CALIFORNIA 94533 (916) 758-0299 THOMAS C. CLARK HAYWARD OFFICE SCOTT R. BENNETT TELEPHONE (707) 426-5300 (510) 887-0977 STEVEN R. CLAWSON FAX (707) 425-7785 NAPA OFFICE (707) 944-1221 RICHMOND OFFICE (S10) 235-1028 VACAVILLE OFFICE May16 1995 (707) 446-0191 Y 7 VALLEJO OFFICE (707) 643-7224 WOODLAND OFFICE (916) 666-1090 Board of Supervisors County Administration Building 651 Pine Street Room 106 Martinez, California 94553 Re: Claim of Michelle Gutierrez Dear Clerk: Enclosed please find the original and one copy of the Board of Supervisors of Contra Costa County's Claim regarding Michelle Gutierrez. Please provide this office with an endorsed filed copy of the same in the self addressed stamped envelope enclosed. If you have questions, please call. Very truly yours, WELLS, CALL, CLARK & BENNETT STEVEN R. CLAWSON SRC/pm Enclosure E D ERVISORS CO. CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA t Claim Against the County, or District governed by) J �U 4 1CT W 5 the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to ) The copy of this document mailed to you is your 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: $126.97 ��Q Sauection 913 and 915.4. Please note all "Warnings". CLAIMANT: Shawn Huff P11AY 2 2 COUNTY COUNSEL ATTORNEY: MARTINEZ CALF F. Date received ADDRESS: 539 Napa Avenue BY DELIVERY TO CLERK ON May 22, 1995 Rodeo, CA 94572 BY MAIL POSTMARKED: May 20, 1995 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. DATED: may 22, 1995 gyIL BATCHELOR, Clerk II. FROM: County Counsel TO: Clerk of the Board of Supervisors ( L-L.-fhis 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: a — S S BY: �� Deputy County Counsel III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. 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 dat`ee'. Gated: u.4AX F3 1 9 9 S PHIL BATCHELOR, Clerk, By Deputy Clerk �� WARNIi!G (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. * For Additional Warning See Reverse Side Of This ?notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 19; 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: ,5' _ BY: PHIL BATCHELOR by Deputy Clerk CC: County Counsel County Administrator l Clai- to: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT , A. Claims relating to causes of action for death or for injury to person or to per- sonal property or growing crops and which accrue on or before December 31, 1987, must be presented not later than the 100th day after the accrual of the cause of action. Claims relating to causes of action for death or for injury to person or to personal property or growing crops and which accrue on or after January 1, 1988, must be presented. not later than six months after the accrual of the cause of action. Claims relating to any other cause of action must be presented not later than one year after the accrual of thecause of action. (Govt. Code 5911.2.) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street, Martinez, CA 94553. C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. E. Fraud. See penalty for fraudulent claims, Penal. Code Sec. 72 at the end of this form. RE: Claim By ) Reserved for Clerk's filing stamp SyNown RECEIVE® ) . Against the County of Contra Costa j MAY 2 2 District) CLERK BOARD OF SUPERVISORS Fill in TL3m8 ) CONS TA C� . � 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) _-_ Ady6g,. 0,+ 2. Where did the damage or injury occur? (Include city and county) .� �'1�Y0� COS A C„QU�1'1)U c� +nt CCrn� O P COYJ Ca rd► A- a 3• How did if `171aY1"� the damage or injury occur? (Give full details; use extra paper required) UJ_Q vxrc.. iuL '1=__�?Con C U rel ��n v� , yJ e _ d 1, �v1 u. What particular act or omission on the part of county or district officers, servants or employees caused the injury or damage? to i I �,re o f Cooirz;L C os-ta Co"iil fio (nave. +"e ` 5. � wnat are the names of county or district officers, servants or employees causing the 'damage or injury? 5. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage. _7i a _o-nd o-1 din v-nei+ dl �.M e .. to iss-cd I_W-Drv- daq 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) MCV+ 4-3 -99 M'�S5cd WOOL 51hou.r_m� - $. Names and addresses of witnesses, doctors and hospitals. % 30.00 W1�YleSS ie1 S� ao50 ScJexu.S PY' Vai�e"S� 5�q ..� cx,e C.s 0. C.� '101) L��S•1 1�t'i•t 5„n g y u-an,� � a ire l o to e . E7 �-7 o-) -3 901 9. List the expenditures you made on account of this accident or injury: DATE ITEM AMOUNT -{3 .9 C1 3�a4 �qJ CA.�i�h r1n��+ � � G'�•a .. * * .* * air • . * * Gov. Code Sec. 910:2 provides: "The claim must be signed by the claimant SEND NOTICES TO: (Attorney) or by some person on his behalf." Name and Address of Attorney f Claimant's Signatur ddress �I s 761 Telephone No. Telephone No. 570 -7qq ' 151 s �tIt * * * NOTICE Section 72 of the Penal Code provides: "Every person who, with intent to defraud, presents for allowance or for Payment to any state board or officer, or to any county, city or district board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account, voucher, or writing, is punishable either by imprisonment in the county jail for a period of not more than one year, by a fine of not exceeding one thousand ($19000), or by both such imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ($10,000, or by both such imarisonr.�ent and fine. G1C 'twi Cortra Costa bq Shawn L r 5 -the r eS � h� - CT : .hale '(r►: - __ _ _ 1a"e Gas -S)d trmmlCdiate : OOaY-1 .arm C.+ ,. We 51OLOLA A rvO10- dk OV CA, Oen -urn e _ rri �1+ 1A9 e t�nm-ed,i cktcb,4 . p u) le pmt on mq spare y l V Q r -14 �_ t+ V" oo L5� 'a i CLAIM I �, BOARD OF SIL ERV; ORS OF CONTRA COSTA COUNTY, CALIFORNIA June 13, 1995 Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to ) The copy of this document mailed to you is your 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: $250,000.00 Section 913 and 915.4. Please note all "Warnings". CLAIMANT: Darrell J. Mooring Sr. RZ ATTORNEY: MAY 17 1995 -COUNTYMARTINEZp���' received �, 17 1995 ADDRESS: 901 Court St. � DELIVERY TO CLERK ON y Martinez, CA 94553 - BY MAIL POSTMARKED: Interoffice Mail I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. _ DATED: May 17, 1995 PpHHIL BATCHELOR, Clerkal BY: D putt' II. FROounty 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: 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 V 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: PHIL BATCHELOR, Clerk, ByPdADeputy 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. * For Additional darning See Reverse Side Of This Notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: BY: PHIL BATCHELOR by Deputy Clerk CC: County Counsel County Administrator Claim"U: : BOARD 0F,SUP OF ODN7 A ODSTA 000N 'Y INSTRucTioNS m CLAIMANT A. Claims relating to causes of action for death or for injury ".o. person, or to per- sonal property or growing crops and which accrue on or before Deeember 31, 1987, must be presented not later than the 100th day after the accrual of the cause of action. Claims relating to causes of action for death or for injury to person or to personal property or growing crops and which accrue on or after January 1, 19889 must be presented not later than six months after,the accrual' of the cause of action. Claims relating to any other cause of action must be presented not later than one year after the accrual of the cause of action. (Govt. Code §911.2.) B. Claims must be filed with the Clerk of the Board of Supervisors at its office In Room 106, 'Cosnty Adainistration Building, 651 Pir:e Street, Martinez, CA 945530 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 riled against each public entity. E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at the end of this form. s s * • ! s * ! * * s a • • • • s f • • s i i • a 0 s • s • s s ; f • s s s 9 a i • f RE: Claim By ) Reserved for Clerk's filing stamp _,OA AS F � RlEC� EiViE® . Against the aunty of Contra Costa or ) 'my 1710 District) CLERK BOARD OF SUPERNISORSI Fill in name ) e —COSIT-11 c1 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: 2. When did the damage injury occur (Give exact date and hour) 2. Where did the damage or injury occur? (Include city and county) 3• How did the damage or 1 ury cc ? (Give dill details; use extra paper 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) 5. 'What are the f county or district officers, servants or employees causing, the iaaaie Cr injury? �r �S�l S /�<•1/ �.- � - ti ' 5. What damage or injuries do you claim resulted? (Give full extent of injuries or. damages claimed. Attach two estimates for auto damage. L.� 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) B. Names and addresses of Witnesses, doctors and hospitals. / 'D , 9. List the expenditures you made on account of this accident or injury: DATE ITEM AMD= Y ..# 11 * • � ! f � ! i • f #=f -f =�: !fi_:f".s;1i�i � i • • � i f f � � f f f 4 f f f S i • * • � Gov. Code Sec:. 910.2 provides: Nei "The"The claim must be signed by the claimant SEND NOTICES TO: (Attornev) or by someperson-)on his behalf." !Jame and Address of Attorney ® Claimant's S gnature Address Telephone No. Telephone No. ss * • fefIr • saas • ee • sa NOTICE Section 72 of the Penal Cade provides: "Every person who, .with intent to defraud, presents for allowance or for Payment to any state board or officer, or to any county, city or district board or offieer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, 'account, voucher, or writing, is punishable either by imprisonment in the county jail for a period of not more than one year, by a fine of not exceeding one thousand ($1,000), or by both such imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ($109000, or by both such imprisonment and fine. If r� r a s �m 1' ill IPg ,v VAS YAq .® Q � L�� Iz- .'� z .I C.� � G � 7� VN `� 0 I CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA June 13, 1995 Claim Against the County, or District governed by) BOARD ACTION the. Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to ) The copy of this document mailed to you is your 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: Unknown e, ti*ame_03 O 15 Please note all "Warnings". CLAIMANT: State Farm Insurance Companies MAY 2 2 1995 05-0859-444 ATTORNEY: COUNTY COUNSEL. Dane R�TTIN ZedALIF. ADDRESS: 6400 State Farm Drive , BY DELIVERY TO CLERK ON May 19, 1995 Rohnert Park, CA 94926 BY MAIL POSTMARKED: May 18, 1995 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. DATED: May 19, 1995 PpHHIL BATCHELOR, Cler BY: eputy II. FROM: County Counsel TO: Clerk of the Board of Supervisors ( his claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Gated: �-3"�]y� BY: Deputy County Counsel 1-4 If If 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: PHIL BATCHELOR, Clerk, By 01 Adj 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. * For Additional warning See Reverse Side Of This 'notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: AA 0 __� BY: PHIL BATCHELOR by Deputy Clerk CC: County Counsel County Administrator f ' - STATE FARM State Farm Insurance Companies ®® INSURANCE May 18, 1995 Claim Office P.O. Box 39 Pleasanton CA 94566-0003 (510)847-2500 .Clerk of the Board of Supervisors lst Floor County Administration Bldg. ------IMPORTANT------ 651 Pine Street PLEASE WRITE OUR Martinez CA 94553 CLAIM NO. ON YOUR REPLY. THANK YOU. RE: Our Insureds: Marc Holtzinger and Gary Holtzinger Our Claim No. 05-0859-444 RECEIVED Date of Loss: 3-12-95 h MAY 19 1996 CLERK BOARD OF SUPERVISORS Gentlemen: i CONTRA COSTA CO. State.Farm Mutual Automobile Insurance Company on behalf of Marc and Gary Holtzinger, hereby make claim against Contra Costa County and make the following statement in support of the claim. 1. Notices concerning this claim should be sent to State Farm Insurance Companies, 6400 State Farm Drive, Rohnert Park, CA 94926, referencing the above claim number. 2. The date and place of the accident giving rise to this claim are: March 12, 1995 at the intersection of Danville Blvd. and La Serena in Alamo, California. 3. The circumstances giving rise to this claim are as follows: Marc Holtzinger was preparing to make a left turn onto Danville Blvd. at the intersection of Danville Blvd. and La Serena when his view was obstructed by shrubbery and trees along Danville Blvd. The view of James Pitto, driving southbound on Danville Blvd. was also obstructed by the same shrubbery and trees. 4. James Pitto was injured. His injuries include back pain and neck pain for which he is still receiving treatment. 5. The total amount of our claim is unknown at this time. HOME OFFICES: BLOOMINGTON, ILLINOIS 61710-0001 Contra Costa County May 18, 1995 Page 2 Notice: This form is to provide notice of our claim for damages in accordance with the 100-day statute. If this form is not acceptable for compliance with the statute, please rush the necessary forms to my attention for proper filing. Sincerely, Sue Eurek Claim Specialist State Farm Mutual Automobile Insurance Company (510) 847-2530 SE/ml/03/0517005 Enclosures: Envelope Date By C1 G. Z U) p C7 C-- -33 m C) C') W � eel' T T_ C1 m r i :r ,97 CO 3 t Y t P RRA Y r►+ l � l �! CLAIM BOARD OF SUPERVISORS OFfCONTRA COSTA COUNTY, CALIFORNIA t - I June I3;`19950 Claim Against the County, or District governed by) BOARD ACTION the Board of .Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to ) The copy of this document mailed to you is your 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: $1,861.37 r».-�-, ^l Section 913 and 915.4. Please note all "Warnings". CLAIMANT: Mel Swafford MAA Q ATTORNEY: `s 1995 COUNTY COUNSEL IdINEZCALIF. Date received ADDRESS: 3030 Frandoras Circle BY DELIVERY TO CLERK ON May 23, 1995 Oakley, CA 94561 BY MAIL POSTMARKED: May 22, 1995 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. r DATED: May 25, 1995 PpHHIL BATCHELOR, Clerk BY: DeputyIt II. FROM: County Counsel TO: Clerk of the Board of Supervisors ( #w##**'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 Z(A — J BY: ���' Deputy County Counsel III . FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARC 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: 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. * For Additional darning See Reverse Side Of This Notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 19; and that today I deposited in the United States Postal Service in Martinez, California, postace fully prepaid a serol"Jed copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. , Dated: I gBY: PHIL BATCHELOR by LJL)Deputy Clerk Cc: County Counsel County Administrator d did • f t V 7�v 1 e � � o w $ � o o V o 3: 0 a Claim *to: BOARD OF SUPERVISORS OF CONTRA COSTA COUN'T'Y n INSTRUCTIONS TO CLAIMANT A. Claims relating to causes.of action for death or for injury to person or to per- sonal property or growing crops and which accrue on or before December 31, 1987, must be presented not later than the 100th day after the accrual of the cause of action. Claims relating to causes of action for death or for injury to person or to personal property or growing crops and which accrue on or after January 1, 1988, must be presented not later than six months after the accrual of the cause of action. Claims relating to any other cause of action must be presented not later than one year after the accrual of the cause of action. (Govt. Code §911.2.) B. Claims must be filed with the Clerk of the Board. of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street, Martinez, CA 94553. C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filsd against each public entity. E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at the end of this form. RE: Claim By ) Reserved for Clerk's filing stamp X e C,4 d LJA RECEIVED 3 Against the County of Contra Costa ) ) MAY 2 3 1995 or District) CLERK BOARD OF SUPERVISORS Fill in name ) „� CONTRA COSTA CO. The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District- in the sum of $ /, / 2 7 and in support of this claim represents as follows: -------------------------------------------------------------------------------- 1. When did the damage or injury occur? (Give exact date and hour) - 2� M 2. Where did the damage or injury occur? (Include city and county) -------------------- 3. How did the damagf� Or injury oc ur? (Give full details; use extra paper if required) ------------------- 4. What particular act or omission on the part of county or district officers, servants or employees caused the injury or damage? Je o4a, -e oPES C cgs ;'o►J I Colt ZD AJ OT OU e !M y /10 s - ,45,e �� IVo�y 9 �r AV r. (over) 5. What are•the names of county or district officers, servants or employees causing the damage or injury? 6. What damage or injuries do you claird 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.) ktL) 8. Names and addresses of witnesses, doctors and hospitals. ------------------------------------------------------------------------------------- 9. List the expenditures you made on account of this accident or injury: DATE ITTEEM j l AMOUNT :y 1i Gov. Code Sec. 910.2 provides: "The claim must be signed by the claimant SEND NOTICES TO: (Attorney) or by so ee - on his behalf." Name and Address of Attorney , Claimant's Sig ture v � Address Telephone No. Tclepho--. No. NO T I C E Section 72 of the Penal Code provides: "Every person who, with intent to defraud, presents for allowance or for payment to any state board or officer, or to any county, city or district board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account, voucher, or writing, is punishable either by imprisonment in the county jail for a period of not more than one year, by a fine of not exceeding one thousand ($1,000), or by both such imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ($10,000, or by both such imprisonment and fine. 5. What are the names of county or district officers, servants or employees causing T ' the damage or injury? ' 5. what damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage. 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) --------------- --------------- 8. Names and addresses of witnesses, doctors and hospitals. ------------------------------------------------------------------------------------- 9. List the expenditures you made on account of this accident or injury: DATE I7 �1., j l AMOUNT s�-.P �/i f�G/1•l J Sij��� Gov. Code Sec. 910.2 provides: "The claim must be signed by the claimant SE"ID NOTICES TO: (Attorney) or by some per§on on his behalf." Fane and Address of Attorney Claimant's Si tore qnvAddress Telephone No. A-1eph7 cn No. 7RZ2.L7 � • " sf ; * TT"i��Fit NOTICE Section 72 of the Penal Code provides: "Every person who, with intent to defraud, presents for allowance or for payment to any state board or officer, or to any county, city or district board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account, voucher, or writing, is punishable either by imprisonment in the county jail for a period of not more than one year, by a fine of not exceeding one thousand ($1,000), or by both such imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ($10,000, or by both such imprisonment and fine. • LEFr2'855I FEE DETAIL INQUIRY PRESS PF3 'FOR ASSESSOR TRACT LOT PERMIT: CC BI AD '180708 PARCEL: 052 082 005 1 TRACT: 4401 LOT: 24 CITY: OWNR: SWAFFORD MELBURN J & LYNDA L SITE: 3030 FRANDORAS CIR OKLY PROJECT DESC: 1ST & 2ND STORY ADDTNS TRA: 53 AS OF: 09 01 92 TOTAL -ITEMS : 9 $ $ 3118 . 09 PAGE : 1 OF . 1 PREFIX: DESCRIPTION: DUE : PD: PAID: DATE: RCPT: INT: SP1 BLDNG PMT 989 . 50 PD 09 01 92 300682 IMC PC PLNPROSFEE f43 . PD 09 01 92 300682 IMC ES ENGYSURPMT408 . 1 PD 09 01 92 300682 IMC E16 ELEC ADD. . 50 PD 09 01 92 300682 IMC PL9 PLMB ADD 47 . 50 PD 09 01 92 300682 IMC M9 MECH ADD 42 . 00 PD 09 01 92 300682 IMC OOP COMDEVCHG 709 . 87__ _ PD -- 09 01 92 300682 IMC ERDA DA 56 X205 ._36--_RDD-- 09 01 92 300682 IMC EQ EQUAKE FEE 20 . 00 PD 09 01 92 300682 IMC FEE TOT 3118 . 09 DUE APPROVED CC 02/22/95 DATE: 09 01 92 4BI 7p2 =-=PC LINE 4 COL 16 fo'g'ey ANTtaCH UNIFIED SCHOOL DISTRICT ^�10,"G',STREET - P.O: BOX 768-ANTIOCH, CA 94509-0504 1966 Paid -to SWAFFORD , MEL 3030 FRANDORAS CIR OAKLEY , CA 94561 Amount ***$2 , 719 . 20*** Date 03/23/95 J Memo : DEV FEE REFUND D E S C R I P T I O N Debit Credit ASN. .867747 S/I FEES MATCHING 2 , 719 . 20 COUNTY OF CONTRA COSTA BUILDING INSPECTION DEPARTMENT .tom MARTINEZ, CALIFORNIA 94553 U' IJ 1) I !::. o 09/01/92 L..0C I::%.i I,R0M TA'rl...0FI-It:?M1:::;3 PiAGL'"•. 1 01: 1 c!- 1 Y R 0 N T 0"T,A I... F,l:i:1:;1") 0`s' k•)i x..)(..)r..)(.:..j(..y(•.I(..y, a(.p•..j(..l1. ,;..,�.j, :,;..)(X")i 4..u; r:?1:'l:: 1::'I.iai:'I;:;i.lx..01' F:: 1.) F, >f1i`'rl?LIi�IF 1 010,0 z . 0 F z 0 U ' 4COUNTYG INSPECTOR P9 REV.6/89 APPLICANT COPY by: C CLAIM �, `ate, BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA June 13, 1995 Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to ) The copy of this document mailed to you is your 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: Unknown Section 913 and 915.4. Please note all "Warnings". CLAIMANT: Kermit Axvig MAY 2 2 ATTORNEY: Clyde I. Butts, Esq.CoUNTYCOUM8eL Date received MARTINEZ CALlr% ADDRESS: 1225 Alpine Rd. , Ste. 204 BY DELIVERY TO CLERK ON May 22, 1995 Walnut Creek, Ca 94596 BY MAIL POSTMARKED: May 19, 1995 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. DATED: May 22 1995 gtIL Dep�tyLOR, ClerjA k , 11. FROM: County Counsel TO: Clerk of the Board of Supervisors ( v/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: ' Qj -�� BY: Deputy County Counsel III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. 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: 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. * For Additional Warning See Reverse Side Of This Notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: f 9 BY: PHIL BATCHELOR by Peputy Clerk CC: County Counsel County Administrator miry -10- 114 U_L. K 1 bK MHNHlatI9tN I I U t91!Ji Cla?r to: BOAP,D OF SUPERVISORS OF CONTRA C=A COUNTX INSTRUMONS TO CLADOM A. Clai= relating to causes of action for death or for injury to person or to per- sonal prope.^ty ar growing crops and which accrue on or before December 31, 1987, must be presented not later than the 300th day after the accrual of the cause of action. Claims relating to causes of action for.death or for inJury to person or to personal property or growing crops and utich accrue on or after January 1, 1988, must be presented not later than six months after the accrual of the cause of action. Clai= relating to any other cause of action must be presented not later than one year after the accrual of the Cause of action. (Govt. Code §911.2.) B. Clai= must be filed with the Clerk of the Board of Supervisors at its office in Room 3.06, County Administraticn 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 rime 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 zt the end of this Foam Ry: Claim By ) Reserved for Clerk's filing Stamp KERMIT AXVIG RECEIVED Against the County of Contra Costa } and/or MAY 2 2 FA ) Merrithew Memorial Hospital District) CLERK BOARD OF SUPERVISORS Fill —n name CONTRA COSTA CO. The undersigned cJaivant hereby makes claim a�ai�st gtht County of Contra Costa or the above-reamed District in the S= of $ c c rnnr i n o and in support of this clam represents as follows: 1. When did the damage or injury occur? (Give exact date and hour) P'larch 15, .1995, at approximately 7 : 00 p.m. 2. Where did the damage cr injury occur? (Include city and County) MerrithewMemorial Hospital, Martinez, Contra Costa County, California 3. flow did the dame or injury occur? (Give full details; use extra paper if required) Injury occurred to Claimant' s wife, Margaret Axvig, as a result of a trigger point injection that was given to relieve numbness and tingling in Claimant' s wife' s. right arm and fingers. 4. What particular act or omission on the part of county or district officers, servants or employees caused the injury or damage? The aforementioned. trigger point injection was negligently and carelessly performed and as a result thereof, Claimant' s wife, Margaret Axvig, suffered a pneumothorax causing he�r� to be hospitalized for approximately 10 days at Merrithew Memorial Hospital. TOTAL P.01 I"IH'i-lc-1�� 14 c:i 1-KU'1 (_ U KISK MHNHUt1'1ttli IU 'J74,'iY:4 r.PiI ^ \_ 5. wnaL are :.ne nes of county or district officers, servants or employees causing the da ag,_ or in jun - Richard McNabb, M.D. , and Does 1 through 25 . 5. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damge. Loss of consortium, loss of love, society, comfort, ,and affection. 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) Unknown at. .this time. 6. Names and addresses of witnesses, doctors and hospitals. Richard McNabb, M.D. and various staff physicians, nurses, and/or other hospital employees at Merrithew Memorial Hospital. 9. List the expenditures you made on account of this accident or inJury: DD A ATE ITS A2it?JT Unknown at .this time. e e e � � � ;� rE � .* � �• � � � ;� � � •� e.e It � �• � � � ,� � ;f * � e e � � � � e e e :t Gov. Code Sec. 910:2 provides: "The claim must be signed by the claimant SEBA NOTICES TO: (Attorney) 'or by some person on 4s behalf." Name and Address of Attorney Clyde I . Butts., Esq. (#.88020). Law Offices of' Clyde :I. Butts Clyde I. CBtIsoSignature)half. of Kermit Axvig 1225 Alpine Road, .Suite 20.4 Walnut Creek, CA 945.96 Address. Walnut Creek, CA 945.96 Telephone No. (510). 943-1850 Telephone No. (510) 943=1850 epee * e * rtiF' i�' NOTICE Section 72 of the Penal Code provides: "Every person who, with intent to defraud, presents for allowance or for payment to any state board or officer, or to any county, city or district board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill., account, voucher, or writing, is punishable either by imprisonment in the county jaill for a period of not more than one year, by a fine of not exceeding one thousand ($1,000), or by both such imprisonment and fine, or by imprisonment in the State prison, by a fine of not exceeding ten thousand dollars ($10,000, or by both such L pr s=nneent and fine_ TOTAL F.©1 $ f � \ ® � a � % � m \ j � \ � �\\ e �\ ) Ln j � / ° R 0 N o > @ n o . . p ~ � \ > 0 . 2 . CA \ l « C ��® » p» � \ , . � � • ! Law Offices of CLYDE I. bUTT6 REQ EIVED cSuite 204 MAY 2 2 1995 1225 Alpine Road Walnut Creek, California 94596 (510) 943-1850 CLERK BOARD OF SUPERVISORS Fax(510)943-7994 CONTRA COSTA CQ. May 19, 1995 Clerk of the Board of Supervisors. Room 106, County Administration Building 651 Pine Street Martinez, CA 94553 Re: Kermit Axvig Dear Clerk: Enclosed please find the original and.one copy of a Claim on behalf of our client, Kermit Axvig. Your cooperation in filing this Claim and returning a "received" copy to our office in the self- addressed, stamped envelope will be greatly appreciated. Should you have any questions,please do not hesitate to call. Very truly yours, LAW OFFICES OF CLYDE I.BUTTS f CLYDE I. BUTTS CIB:cr Enclosures CLAIM . �a— BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA q June 13, 1995 Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to ) The copy of this document mailed to you is your 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: Unknown Section 913 and 915.4. Please rote allc. "Warnings". CLAIMANT: Margaret A,:vig y MAY 2 2 1995 ATTORNEY: Clyde I. Butts, Esq. COUNTY CCU �g MARTINEZC ffi�received ADDRESS: 1225 Alpine Rd. , Ste. 204 BY DELIVERY.TO CLERK ON May 22, 1995 Walnut Creek, CA 94596 May 19, 1995 BY MAIL POSTMARKED: I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. PpHHIL BATCHELOR, Clerk DATED: May 22,1995 BY: Deputy II. FROM: County Counsel TO: Clerk of the Board of Supervisors ( his claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section'911.3). ( ) Other: Dated: 'a 3 � BY: Deputy County Counsel III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. 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: 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. * For Additional Warning See Reverse Side Of This Notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: 14, 1 QS,5_ BY: PHIL BATCHELOR by eputy Clerk CC: County Counsel —` County Administrator r-KUM U(-(- H 16K MHNHUtr t;11 t u Clair tc: BOAP.D OF SUPERVISORS OF CONTRA COSTA COJIM INMUCTIONS TO CLAD1ANT A. Clai.:s relating to causes of action for death or for injury to person or to per- sonal property ar browing crops and which accrue on or before December 31, 1987, must be presented not later than the 300th day after the accrual of the cause of action. Claims relating to causes of action for.death or for injury to person or to personal property or growing crops and Which accrue on or after January 11 1988, must be presented not later than six mmtha after the accrual of the cause of action. Claims relating to any other cause of action must be presented not late." than one year after the accrual of the cause of action. (Govt. Code §91.1..2.) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street, Martinez, CA 91553. C. If claim is against a district governed by the Board of Supervisors, rather, than the County, the rime of the District should be filled in. D. If the c?.aim 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 zt the end of this for= RE: Claim By ) Reserved for Clerk's filing stamp MARGARET AXVIG ) RECEIVED Against the County of Contra Costa MAY 2 2 M and/or ) Merrithew Memorial Hospital District) CLERK BOARD OF SUPERVISORS Fill in name) CONTRA COSTA CO. The undersigned claimant hereby makes clIroof, m wai st tt�e County of Contra Costa or the above-named District in the sum of $ ing ° and in support of .this claim represents as follows: I. When did the damage.or injury occur? '(Give exact date and hour) _ March 151995, at approximately 7 : 00 P.m. 2. Where did the damage or injury occur? (Include city and county) Merrithew Memorial Hospital, Martinez , Contra Costa Co»nty_ ,lyfaLrnia 3. How did t1he damage or injury occur? (Give .full details; use extra paper if required) Injury occurred to Claimant as a result of a trigger point injection that was given to relieve numbness and tingling in Claimant's right arm and .finger-s. 4. What particular act or omission on the part of county or district officers, servants or employees caused the injury cr damage? The aforementioned trigger point injection was negligently and carelessly performed and as a result thereof, Claimant .suffered a pneumothorax causing her to be hospitalized for approximately 10 days at Merrithew Memorial Hospital. TOTAL P.01 MHY-to-ly� , 14 G i FROM CCC RISK MHNHUEMt:4I I U Ul 7. wnat: are the nam-_s of county or district.officers, servants or employees causing the n or in jLu-y"? Richard McNabb, M. D. , and Does 1 through 25. 5. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage. Pneumothorax causing permanent injury, including but not limited to weakness and shortness of breath upon exertion, continued pain and suffer- 4P IF 9 1 low was the amount claimed above computed? (Include the estimated amount of any prospective injury or, damage.) Unknown at this time. $. ?lames and addresses of witnesses, doctors and hospitals. Richard McNabb, M.D. and various staff physicians, nurses, and/or other. hospital employees at Merrithew Memorial Hospital. 9. List the expenditures you made on account of this accident or injury; DATA, ITS Al��it+'NT Unknown at this time. � � � IF � �F #F it � .* � � � iE � � iF � •fir �.* � ! � i! # * # � � i! � � � * � � iF It iF � � Gov. Code See. 910:2 provides: "The claim must be signed by the claimant SEND NOTICES TO: (AttoMe ) or by some 2erson on his behalf." Name and Address of Attorney Clyde I. Butts, Esq. (#88020) , gra Law Offices of Clyde I. Butts C e I.(ClButtsson behalf of Margaret Axvig 1225 Alpine Road, Suite 204 1225 Alpine Road, Suite 204 Walnut Creek, CA 94596 Address, .Walnut . Creek, CA 94596 Telephone No.(510) 943-1850 Telephone No. (510) 943-1850 /F NOTICE Section 72 of the Penal Code provides: "Every pee„son who, with intent to defraud, presents for allowance or for payment to any state board or officer, or to any county, city or district board or officer, authcrized 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 jaill for a period of not more than one year, by a fine of not exceeding one thousand ($1,000), or by both such imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ($10,000, or by bath such Lmpprisonneent and fine. TOTAL P.01 Law off ce,5 of CLYDE 1. BUTTS &Le 204 RECEIVE 1225 Alpine goad _ Walnut Creek, California 94596 15101943-1850 MAY 2 2 1995 Fax f5101 943-7994 CLERK BOARD OF Sl!PERVISORs I CONTRA COSTA Co. May 19, 1995 Clerk of the Board of Supervisors Room 106, County Administration Building 651 Pine Street Martinez, CA 94553 Re: Margaret Axvig Dear Clerk: Enclosed please find the original and one copy of a Claim on behalf of our client, Margaret Axvig. Your cooperation in filing this Claim and returning a "received" copy to our office in the self- addressed, stamped envelope will be greatly appreciated. Should you have any questions, please do not hesitate to call. Very truly yours, LAW OFFICES OF CLYDE 1. BUTTS CLYtELBUTTS CIB:cr Enclosures yr o .o a � N U t� c arn t,J i w rn CO 0 'v a � _