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HomeMy WebLinkAboutMINUTES - 07122006 - C.40 CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY V BOARD ACTION: AUGUST 15, 2006 Claim Against the County, or District Governed by ) the Board of Supervi's'ors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All"Section references are to ) The copy of this document mailed to California Government Codes. Y you is your notice of the action taken on your claim by the Board of JUL 12 2006 fit Supervisors. (Paragraph IV below), given Pursuant to Government Code AMOUNT: $132000.00 COUNTY COUNSEL Section 913 and 915.4. Please note all MARTINEZ CALIF. "Warnings". CLAIMANT. TRISTAR RISK MANAGEMENT ON BEHALF OF VIOLA GARCIA ATTORNEY: BY: KATHLEEN M. SUNDERLA%ATE RECEIVED: JULY 12, 2006 UNKNOWN ADDRESS: P.O. BOX 9350 BY DELIVERY TO CLERK ON: JULY 127 2006 WALNUT CREEK, CA 94598 BY MAIL POSTMARKED: HAND DELIVERED FROM: Clerk of the Board O'S TO: County Counsel Attached is a copy of the above-noted claim. JULY 12, 2006 JOHN CULLEN, r Dated: By: Deputy 11. FROM: County Counsel TO: Clerk of the Board of Su ervisors I ( 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. IThe Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). O Other +� I I Dated: �— l 2 -OCP I By: M w�, Deputy County Counsel III. FROM: Clerk of the BI�and TO: County Counsel (1) County Administrator(2) O Claim was returned as untimely with notice to claimant (Section 911.3). V CARD ORDER: Bynanimous vote of the Supervisors present: This Claim is rejected in full. O Other: 1 certify that this is I true and correct copy of the Board's Order entered in its minutes for this date. Dated: .AclN CULLEN, CLERK, By Deputy Clerk WARNIN (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 rile a court action on this claim.See Government Code Section 945.6.You may seek the advice of an atto mey of your choice um connection with this matter. If you want to eousult an attorney,you should do so unmediately. *For Additional Wamimiug See Reverse Side of This Notice. AFFIDAVIT OF MAILING 1 declare under penalty of per jury 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 I1lartinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dates � a.a.A ,JOHN CULLEN, CLERK By AlpDCpUly Clerk ■ ■ 1!2/22/2005 08:24 CONTP^ COSTA COUNTY CLERK OF THE -> 99300=-;0 NO.645 Doi ■ � BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY '■'■' INSTRUCTIONS_TO CLAIMANT A. A claim relating to a cause of action for death or for injury to person or to personal property or growing crops shall be presented not later than six months after the accrual of the cause of action. A claim relating to any other cause of action shall be presented not later than one year after the aecrual of the cause of action. (Gov. Code § 911.2.) I 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 befilled in. D. If the claim is against more tJhan one public entity, separate claims must be filed against each public entity. J 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 ayl Against the County o Contra Costa) or ) JUL 1 2006 District) CLERK BOARD OF S CONTRA COSTA Co.iSORS (Fill in the name) I ) J ) The undersigned claimant hereby lakes claim against the County of Contra Costa or a above-named district in the sum of S \3,000•i '* and in support of this claim represents as follows-Is )6J c.C,+ *.N 1. When did the damage or iik ury occur? (Give exact date and hour) i 30; X00 CoQ 0—fPX 30 f\m 2. Where did�e orury occur? (Include city and county) �as�arr, SiclluJa�G-Oc- t�-H..e. X100 brick. Lb'C��.vie, Seed hl&XJt►�z, CA &Ge6 *-W oto-yc�� 3. How did the damage or injury occur? (Give full details;use extra paper if required) �rippecl oh une++ ger, s; )C 4. What particular act or oiriission on the part of county or district officers, servants, or employees caused the injury or damage? ?,XD u-� s cam,J s.A o� ,fir c-1efa.4rell. 5 What are the names of county or district officers, servants, or employees causing the damage or injury? UrLV�.r�.�n 12/22/2005 08:24 CONTR^ COSTR COUNTY CLERK OF THE -) 99300"i0 NO.645 R02 6. What damage or injuries do your claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates+for auto damage.) k r A.R,,0 C►!hN I0.m lC'u� 4 i.A' 5h W l deer S wriJ (SJbja- to C ) 7. How was the amount clauned above computed? (Include the estimated amount of any prospective injury or damage.) �eeSed.uy � t'- �dL fe Gsve c�. �t,SzWel; NQA 'Ue 000I�•-a.n&ate. s ub,� Chic.. ao more �s feee ived 8. Names and addresses of witnesses, doctors,and hospil:als: 'T bb 9. List the expenditures you made on account of this accident or injury: DATE iT&M AMOUNT dome........rote.near.........I.,added drawn.■goods.ago.damson.,,,■■,,,,,■■woof■„■.,,, ) Gov. Code Sec, 910.2 provides "The claim shall be ) signed by the claimant or by some person on his behalf," SEND NOTICES TO: (Attorney) Name and address of Attorney j1riClaimant's sign �.,.s�- p o Qdx g3sa, 1tJa .Jr. �a�,k. r4�{S�iS (Address) Telephone No, )Telephone No. GaS-9'1S- y ay t PUBLIC RECORDS NOTICE: Please be advised that this claim form, or any claim filed with the County under the Tort Claims Act, is subject to public disclosure under the California Public Records Acta(Gov, Code, §§ 6500 et seq.) Furthermore, any attachments, addendum.s, or supplements anacbed to the claim form, including medical records,are also subject to public disclosure, ..................■.....Vosges..■...........,..■.....one.........................woof NOTICE: Section 72 of the Penal Code provides: Every person who, with intent to defraud,upresents for allowance or for payment to any state board or officer, or to any county, city, or district board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account voucher, or writing, is punishable either by imprisonment in the County jail for a period of not more than one year, by a fine of not exceeding one thousand dollars ($1,000.00), or by both such imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ($10,000), or by both such imprisonment and fine. Page I 525 AENRWffA 3T MARTMZi SCA=94553 9M372-3440 �MGPMATtON TIRPOTtT 06467 ORtastt Destripilor Fe1IM id Butt Otearred Time Otenrrtd Arts Hate Printed AIDE MEDICAL 1/30(1006 0836 t05 WI2/2006 Dote Reported Tome Reported Beat 'rime Printed 1/30/2006 0836 t 10:46:59 DlspsdwmDate Disposition lacideethumber 1/302006 information Only 060130012 Location Location Type Point of Entry 700.Pinc St.Martinet,CA 94553 Strmb%ghwuy Maas of Atbtit I Location of Entry Method of Entry Alarm System Keportiog Parry t Vattlm Ataldeaet Addrew J Raid®et Phunc DOH Age See Mavv Busineo Name and Address J Dusiaea Phone— Height Weight Bair F.y" Asalstance RenderedlVittim Disposition JI t'ruagordog Ag Y new aptims of lujuries ++ other laformatift ... . Injured Gallia,Vilon Raldeact Addrm Residence(hunt DOB Age tier Rant 446 Skyherbuur litre,flay Point,CA 94565 _ 5483469 626/1954 51 F H andow Name and Address Bullae"Phone Height Weight Hair Eyes Co.w.co,725 Court St,Martinez,CA 94553 ! 6461505 5' 124 BRO BRO Suspect Name Action Takes. Cherges cddence Addren I Residence Pbont DOS Age Se. Race R Rosiness Name and AZ; Ballot"Placate Hvieht Weight Hair Eyet ldellaying Features Arrest Number Drivers Licente• SSN 5tatru Vehicle Mara and Modd L cam; 9(ate Vt Type I No. Sato team Description Value Val Reeove►d Vat Damaged Solvability Factor - ... Prepared By Dite. Assisted By Approved RI Date 108-Schnobel,Craig 1/30/2006 97-S�tvis, on !/302006 Route To Title Now File 113W2006 Administration j!i0/2006 -• - •---ra n , 7�u7,uuw 0 c,0077c7c vul Ir.-Al OAA7/71 /OA r � Page Z _S25.NVaM7' MMTJNEL,CA-'943Z 925-372-3440 HARR,ATWE tO6-4G7 On 01/30/06 at 0837 hours,I was dispatched to Main St at Pine St.for a report of a fall victim I arrived on scene and did not locate anyone. I made an area check and located a female sitting on the sidewalk in the 700 block of Pine St. The female was later identified as Garcia,Viloa. 1 asked Garcia what happened. She stated she was carrying a box while walking south on the east sidewalk on Ane St. As she stepped down,her ankle twisted and she fell forward. Garcia struck her right knee on the concrete sidewalk. Garcia said she did not hear a pop,but felt pain.Garcia said she could not stand and sat on the sidewalk until help arrived. She later advised her right knee cap had been replaced with an artificial cap. Garcia said while waiting for help,she saw the part of the sidewalk she stepped down on prior to falling had a crack in it. I While on scene with Garcia,AMR arrived. Paramedic Jaysun from ALS unit 154 rendered aid to the victim. Garcia was later'transported to Walnut Creek Kaiser for further treatment. I made an area check and located a cracked sidewalk next tui where I located Garcia_ 1 took several photos and attached them to this case. No one witnessed this incident I occur. NF1 Prepared Ry: J Dart' 108 sc uKABEL,CRAIG I 1/'91�J06 - . •---�. •. ��• ..uum nr innv 7010 VUA Ir. ni onnv/71 /On I POLICE DEPARTMENT � Page I o� 525$ NRIETTA STi 6 MARTINEZ,CA 94553��925 372-3440 6/15/2006 `f w a� � �^z:;a r 4� h"" v r.,� ^,-�U"w'id�T•ivs '$�' 's-N 1��' 40: $�{y�:�dy "j"r � � } �^T��d 5 #�.. � ' � � ��My '`�$c4y ���`�,�� �}';• "�iy 5s..+1lS#�a'^*�.Ys; e . � � 'p s�✓fi$ 2�(�T�si�'$� �FN i ��gR�� �� F�'�£��x,. � �i4^r. R A `� x,- 1 108 2 108 3 CRACK IN SIDEWALK 700 BLOCK OF PINE VIC.DOWN NEXT TO CRACK 1N SIDEWALK ST. VIC. SAID SHE TWISTED HER ANKLE AND FELL ON HER KNEE AS A RESULT OF THIS CRACK. mg t � 4 108 5 108 VIC'S RIGHT KNEE. EAST SIDE OF 700 BLOCK OF PINE ST. Run Date'07/11/2006 Payment Listing Page: 1 of 2 Run Time: 14:05:23 Garcia, Viola 06151540 From Through Check# Check Date Method Vendor Discount Amount Indemnity TEMPORARY DISABILITY 05/09/2006 05/15/2006 354571 05/22/2006 Check Claimant 0.00 672.53 04/25/2006 05/0812006 353334 05/08/2006 Check Claimant 0.00 1,345.06 04/11/2006 04/24/2006 352140 04/24/2006 Check Claimant 0.00 1,345.06 03/28/2006 04/10/2006 350869 04/10/2006 Check Claimant 0.00 1,345.06 03/14/2006 03/27/2006 349781 03/27/2006 Check Claimant 0.00 1,345.06 02/28/2006 03/13/2006 348539 03/13/2006 Check Claimant 0.00 1,345.06 02/14/2006 02/27/2006 347146 02/27/2006 Check Claimant 0.00 1,345.06 01/31/2006 02/13/2006 345958 02/13/2006 Check Claimant 0.00 1,345.06 Totals for TEMPORARY DISABILITY 0.00 10,087.95 Totals for InOemnity 0.00 10,087.95 Recovery 0.00 Medical ATTENDING PHYSICIAN 05/08/2006 05/08/2006 356447 06/14/2006 Check MUIR ORTHOPAEDIC SPECIALIS13.12 46.17 04121/2006 04/21/2006 354412 05/19/2006 Check MUIR ORTHOPAEDIC SPECIALIS' 1.78 57.51 03/10/2006 03/10/2006 351065 04/1212006 Check MUIR ORTHOPAEDIC SPECIALIS' 23.02 122.17 02/14/2006 02/14/2006 350155 03/31/2006 Check MUIR ORTHOPAEDIC SPECIALIS' 4.12 133.26 02/01/2006 02/01/2006 1 Paper Transaction MUIR ORTHOPAEDIC SPECIALIS 192.97 0.00 02/24/2006 02/24/2006 349885 03/2912006 Check MUIR ORTHOPAEDIC SPECIALIS' 5.15 166.25 02/01/2006 02/01/2006 348232 03/0812006 Check MUIR ORTHOPAEDIC SPECIALIS' 5.79 187.18 Totals for ATTENDING PHYSICIAN 245.95 712.54 PRESCRIPTION DRUGS I 04/17/2006 04/17/2006 354397 05/19/2006 Check MEDICAL SERVICES COMPANY 0.04 255.12 04/20/2006 04/2012006 353809 05/15/2006 Check MEDICAL SERVICES COMPANY 0.00 48.61 03/14/2006 03/14/2006 351843 04/20/2006 Check MEDICAL SERVICES COMPANY 0.02 19.29 02/24/2006 02/24/2006 350144 03/31/2006 Check MEDICAL SERVICES COMPANY 0.00 68.21 Totals for 1PRESCRIPTION DRUGS 0.06 391.23 BILL REVIEW- Medical IJ 05/08/2006 05/08/2006 356476 06/14/2006 Check Tristar Managed Care-Bill Review 0.00 0.36 05/08/2006 05/08/2006 356476 06/1114/2006 Check Tristar Managed Care-Bill Review 0.00 1.64 04/21/2006 04/21/2006 354438 05/119/2006 Check Tristar Managed Care-Bill Review 0.00 0.45 04/17/2006 04117/2006 354438 05/19/2006 Check Tristar Managed Care-Bill Review 0.00 0.01 03/10/2006 03/10/2006 351090 04/12 /2006 Check Tristar Managed Care-Bill Review 0.00 0.95 03/10/2006 03/10/2006 351090 04/12/2006 Check Tristar Managed Care-Bill Review 0.00 2.69 02/14/2006 02/14/2006 350186 03/31/2006 Check Tristar Managed Care-Bill Review 0.00 1.03 02/24/2006 02/24/2006 349907 03/29/2006 Check Tristar Managed Care-Bill Review 0.00 1.29 02/01/2006 02/01/2006 348284 03/08/2006 Check Tristar Managed Care-Bill Review 0.00 1.45 Totals for BILL REVIEW-Medical 0.00 9.87 MEDICAUNURSE MANAGEMEt 05/01/2006 05/17/2006 356737 06116/2006 Check Tristar Managed Care Nurse Case 1 0.00 160.00 04/03/2006 04/25/2006 ' 354055 05%17/2006 Check Tristar Managed Care Nurse Case 1 0.00 464.00 02/01/2006 02/28/2006 349108 03/17/2006 Check Tristar Managed Care Nurse Case 1 0.00 256.50 Totals for MEDICAUNURSE MANAGEMENT 0.00 880.50 MEDICAL TRANSPORATION 01/30/2006 01/30/2006 350234 04/03/2006 Check AMERICAN MEDICAL RESPONSE 0.00 50.00 Totals for MEDICAL TRANSPORATION 0.00 50.00 EQUIPMENT&APPLIANCES 02/24/2006 02/24/2006 351062 04/12/2006 Check DEMAR MEDICAUSUPPORT CAR 0.00 630.00 Totals for EQUIPMENT&APPLIANCES 0.00 630.00 Confidential Run By: Run Date 07111/2006 Payment Listing Page:2 of 2 Run Time: 14:05:23 Garcia, Viola 06151540 From Through Check# Check Date Method Vendor Discount Amount Medical I UR/Pre-cert 03/21/2006 03/31/2006 352161 04!24/2006 Check Tristar Managed Care Nurse Case 1 0.00 40.00 Totals for UR%Pre-cert 0.00 40.00 Totals for Medical 246.01 21714.14 Recovery 0,00 Other PHOTOCOPY EXPENSE 05/24/2006 05/24/2006 357932 07/05/2006 Check MED-LEGAL 0.00 259.50 05/12/2006 05/1212006 355316 06101/2j006 Check MED-LEGAL 0.00 216.00 Totals for PHOTOCOPY EXPENSE 0,00 475.50 i Totals for Other 0.00 475.50 Recovery 0.00 Totals for Claim 13,277.59 Recovery 0.00 Confidential Run By: Run'Date: 07/11/2006 Face Sheet Page: 1 of 1 Run Time: 14:16:52 Garcia, Viola 06151540 Status: Open Type: TD Incident Date: 01/30/2006 Closed Date: Opened Date: 02/01/2006 Denied Date: 06/09/2006 Insured Reported Date: 01/30/2006 Deductible: Insured: Contra Costa-JBWCP Classic Courthouse Claimant: Garcia,Viola SSN: 546-11-0214 446 Skyharbor Lane Sex: Female Bay Point,CA 94565 Birth Date: 06/26/1954 Examiner: KSUNDERLAN Hire Date: 12/02/1991 Weekly Wage: 1,008.80 Incident: EE walking and tripped on uneven pavement Type: WALKIRUN Cause: FALUSLIP Body Part: ANKLE(S) Nature of Injury: CONTUSION Total Incurred Payments Outstanding Recovery Indemnity 10,760.53 10,087.95 672.58 Rehab Medical 30,250.00 2,714.14 27,535.86 Legal Other 2,500.00 475.50 2,024.50 Total: 43,510.53 13,277.59 30,232.94 0.00 Contra Costa-JBWCP Confidential i CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY (/ • U IBOARD ACTION: AUGUST 15, 2006 Claim Against the County, or District Governed by ) , the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to ) The copy of this document mailed to California Government Codes. ) you is your.notice of the action taken on your claim by the Board of Supervisors. (Paragraph IV below), given Pursuant to Government Code JUL 1 4 2006 Section 913 and 915.4. Please note all AMOUNT: $1,425.28 °Warnings". jCOUNTY COUNSEL CLAIMANT: ANTHONY LASCANCMARTINEZ CALIF ATTORNEY: UNKNOWN DATE RECEIVED: JULY 14, 2006 ADDRESS: 5194 JOMAR DRIVE BY DELIVERY TO CLERK ON: JULY 14, 2006 CONCORD, CA 94521 JULY 13, 2006 ' BY MAIL POSTMARKED: FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JULY 14, 2006 JOHN CULLEN I Dated: By: Deputy 1I. FROM: County Counsel I TO: Clerk of the Board of S pervisors (,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 Boar dcannot act for 15 days (Section 910.8). { ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). O Other. I I Dated: 7--/"4-DLo By: Deputy County Counsel III. FROM: Clerk of the BIo and TO: County Counsel (1) County Administrator(2) O Claim was returned as untimely with notice to claimant (Section 911.3). 1V. OARD ORDER: By unanimous vote of the Supervisors present: ( This Claim is rejected in full. O Other: 1 certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: 6N CULLEN, CLERK, By Deputy Clerk WARNIN (Gov. code section 913) Subject to certaur exceptions,you have only six(6)mouths 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 au attorney of your choice ur connection with this matter. U you want to consult an attorney,you should do so immediately. 'For Additional Warning See Reverse Side of This Notice. AFFIDAVITOF 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: G *��1GHN CULLEN, CLERK By Deputy Clerk APR-0?-20106 10:02 CSAA L.U2 WA"4S S FRM pub's A vv„I.x ?02 ss? ss4s P.02 TUNS TIF U CL. ASiT A. A claim relating to a cause of action for death or fus injury to petsan or tri personae propedY ear growing crops shall be presented not later dw A mm6s after the mer W of the mw of wtim A claim relating, to any other cazrse of action shall be,pxeserud not latex tJaaa one ym ager t1w accrue]of the cause of action. {Cion:Code 13. Claim must be filed with the Clerk of the Bond of Snavisors at its office in.Room 106, County Administration BttilBiutg, 651 Pine Street,Mudaea,CA 94553. C:, if clam is against a district governed by the Board of Supervisors, rather tb>nt the Coudy,rite w iie of the District atiould ba filled in.i IA If the claixu is against more than onEl p blic adty, separate claims must bo filed against emb public arty. .� 1?- See pmdty for fraudulent claims,Penal Code Sec,72 at the end of this form. eaemamaa*seam aaa0aa•■saamaranaoasells aaa11►eaaaesaM011552R6aanoaikeaas*asasaesao RR Claim Bar Reserved for Clerk's filimig stamp 1 , RECEIVE[) A the Cocmtkof Contra Com.or ) JUL 1 4 ZQ06 CLERK BOARD OF S1jp- t mths aanie) III }a15t�lCt� CONTRA C0^ CRVISORS COSTA co. TU Wdetsigned 0191mattt Eby makes�cldm,against the County of Coma Costa or the above-arced dzateict in the sum,of$. /' and in support of thins alarm represents as follows: 1. Wben did the damage or nnjuty oc� (Crive cxad date ad hour) s`h/9,Ak- cd, .9fs, Zvv � 2. Where did the dannsge or izgury 4GCt3't2 (Include*anti Cour q) v Z>. i�l e�w�oj�/7� G64_ 3. How did the damage or Wuxy occur? (Crive full details;use extm paper if required) Ay C/-e-c 4)'/-e w-e,.w-4-1 cl0/Av y 4. P Nt7'- What� ardm4ar act or omon on the part of wwty or district officer; serums, or employees caused the injury or dauu�ga? y / f `^C}q / /lC—r—/2.. 5 What are tbz names of ootuity Or diStig officers,servants,or employers causing the damage or injtuy? C � rj�, 5�'� �d1foC�� aJcr� FN 9PR-07-2006 10:03 CSPP LV2 I 702 897 8948 P.03 F Wbat damage- or injuries do your claim resulted? (0ive full WMA of injuries or damages ,cl rn& -AV=htwo estimabs for auto damage.) --a . r -e J S `tJ 4 � � y e� 7`0 '-j 4LcyA "r tQ 7. How was the amault claimed ftyle computed? (Itchule t estimated amount of MY Fospee ve mi ffi ry or damage.) --r& 1 I & d - Au v u`T c d t} S G'v•-, p u 7"2cG �y � � �0 y sko� $. Nwies_apd addresses of vhtnesses,doam,and bospitalm: 9. List thea expendlturw you made-onaccount oftbis accident or kimy. DALTE A w /,vS Gc r .a ;G 1`.v ¢ J-e tatnnnasatit atter meaaamaea a*eras tees seers eases■ seeegMaaaesseata McMMta ea6srae■■■Mame .Pov.We Sm 410.2 provides"'Ilse claim shall be signed by the claimant or byw=peom m bis SllrIU NOnm Ta (A e^v1 1 Name atzil address of At mmy ) }! Claimant's Signature} Tel!a*fzallo. i}Teleph=No. 9Z ZZ Note ase ens Matta Menu■as*INA S SUN 94N ISO tMtttattt{O7aSesames ae 80 U f to to ee FnkV t to tewaaans' NOTICE- Ph A a be advised that this claim form,or11imy claimfiled with Sze County underthe".fort Chhw Act,is object 10 public disdosoma under the: Catif'omia Public R=r& Act. (Gov. Coda 65 6500 et sq.) Pur&mam m O► attealnIts,addeadums,or applennmu attached to the claim form„including medical momds,ate also sdiectlo public Mtlt tpRr+lla etas ata■aaR■MttI a■seemmMaasaonsaaaea Renal no tear nasaaeatnet■rases■*•esi NOTICE. S'ecti n 72 of the Penal Cade provides: Brerp person who,with intent to defzaud,presents for allowatoo or for payment to any state board or officer.at W any couily, city, or district board f or offieer, eabaezed to allow or pay the same if gcuuiaa, any fame of fiudutest claim,bili,account voucber,or writing,is punishable either by tmp tonmmt in the County ion for a period of not more than one year, by ja fine of not weeding taus thousand dollars($1,000.00), or by bA sa& hR4isontaeM and fma,or by imprimamcut in the state prisoa, by a fine of not ax ft&g tan thousand doll= ($10,000),cc by both much itnprisonnnem and fine. TOTAL P.03 Date: 4/13/2006 11:05 AM +p a cl 7 f: Estimate ID: A20500975801 7 d Estimate Version: i Supplement: 1 (F) 4/13/2006 10:36; COMPLETED Preliminary COMPLETE FINAL Profile ID: CSAA DRN Mike Rose Auto Body, Inc. 2260 Via De Mercados Concord, CA 94520-4920 (925) 689-1739 Fax: (925) 689-0991 Tax ID: 94-2621349 BAR #: 0969527 EPA#: CAR 000004317 Damage Assessed By: JOHN GLOYN Appraised For: Glinda Ruthruff Supplemented By: MARK GILLEM Condition Code: Good Type of Loss: Collision Date of Loss: 3/28/2006 Final to Owner; 4/13/2006 Payer: Insurance Deductible: 250.00 File Number: F Claim Number: A20500975801 Insured: RACHEL LASCANO Mitchell Service: 912494 Description: 2002 Buick Century Custom Body Style: 4D Sed Drive Train: 3-IL Inj 6 Cyl 4A FWD VIN: 2G4WS52J621289556 License: 4YFP139 CA Mileage: 63,645 OEM/ALT: A Search Code: C754827 Color: BURG Options: ALUM/ALLOY WHEELS, AIR CONDITIONING, POWER STEERING, POWER WINDOWS POWER DOOR LOCKS, TILT STEERING WHEEL, CRUISE CONTROL, ELECTRIC DEFOGGER AUTOMATIC TRANSMISSION, AM-FM STEREO/CDPLAYER(SINGLE) "ALL CRASH PARTS ON THIS ESTIMATE ARE "NEW" ORIGINAL EQUIPMENT MANUFACTURER PARTS, UNLESS OTHERWISE SPECIFIED. PARTS DESCRIBED AS RECHROMED,RECORED,REMANUFACTORED OR, RECONDITIONED ARE CONSIDERED "REBUILT" PARTS. CRASH PARTS DESCRIBED AS "QUALITY REPLACEMENT PART" ARE NON-ORIGINAL EQUIPMENT MANUFACTURER AFTERMARKET NEW PARTS" Line Entry Labor Line Item Part Type/ Dollar Labor Item NumberType Operation Description Part Number Amount Units S11 201484BDY REMOVE/REPLACE R FRT DOOR POWER MIRROR ASSY 10316956 GM PAR"153.99 *0.3 # 2 AUTO REF REFINISH R FRT MIRROR COVER C 0.4 3 200735BDY REMOVE/INSTALL R FRT DOOR TRIM PANEL 0.4 4 200815BDY REPAIR R REAR DOOR SHELL Existing 1.0* 5 AUTO REF REFINISH R REAR DOOR OUTSIDE C 2.2 6 202511BDY REMOVE/INSTALL R REAR.UPR REVEAL MOULDING 0.3 7 200823BDY REMOVE/INSTALL R REAR OTR BELT MOULDING 0.3 8 200825BDY REMOVE/INSTALL R REAR LWR DOOR MOULDING 0.3 9 202513BDY REMOVE/INSTALL R REAR DOOR ADHESIVE MOULDING Existing 0.2* 10 900500BD1* ADD'L LABOR OP CLEAN AND RETAPE RT RR B.S.M. **Qual Repi Part 4.00 *0.3* 11 200841BDY REMOVE/INSTALL R REAR DOOR TRIM PANEL INC ESTIMATE RECALL NUMBER: 4/10/200608:48:49 A20500975801 UltraMate is a Trademark of Mitchell International Mitchell Data Version: MAR_OECopyright (C) 1994- 2003 Mitchell International Page 1 of 3 UltraMate Version: 5.0.214 All Rights Reserved v Date: 4/13/2006 11:05 AM ' Estimate ID: A20500975801 Estimate Version: 1 Supplement: i (F) 4/13/2006 10:36; Preliminary FINAL Profile ID: CSAADRN 12 200867BDY REMOVE/INSTALL R REAR OTR DOOR HANDLE 0.7 # 13 20386OREF REFINISH R QUARTER PANEL EDGE C 0.5 14 203864REF REFINISH R QUARTER PANEL OUTSIDE C 2.1 15 203853BDY REPAIR R SIDE BODY PANEL ASSEMBLY -S Existing 4.5*# 16 RT 1/4 AREA 17 201087BDY REMOVE/INSTALL R REARJCOMBINATION LAMP 0.3 18 201103BDY REMOVE/INSTALL REAR BUMPER ASSY 0.7* 19 LOOSEN RT SIDE 20 900500REF* ADWL LABOR OP SUBSEQUENT VEHICLE BAGGING **Qual Repl Part 0.2* 21 90050OBD)* ADD'L LABOR OP ROPE RT SIDE OF B-GLASS **Qua) Repl Part 3.00 *0.3* S122 900500BD1* ADD'L LABOR OP PANEL RETAINERS **Qual Rep[ Part 19.60 *0.0* 23 AUTO REF ADD'L OPR CLEAR COAT 1.5* 24 933003REF ADD'L OPR TINT COLOR 0.5* 25 AUTO ADD'L COST PAINT%MATERIALS 199.80 * 26 AUTO ADD'L COST HAZARDOUS WASTE DISPOSAL 1.85 * * - Judgement Item # - Labor Note Applies C - Included in Clear Coat Calc Remarks **FINAL EST O.K. TO PAY Add'1 Labor Sublet I. Labor Subtotals Units Rate Amount Amount Totals II. Part Replacement Summary Amount Body 9.6 60.00 0.00 0.00 576.00 Taxable Parts 180.59 Refinish 7.4 60.00 0.00 0.00 444.00 Parts Adjustments 7.70- Sales Tax @ 8.250% 14.26 Non-Taxable Labor 1,020.00 Total Replacement Parts Amount 187.15 Labor Summary 17.0 1,020.00 III. Additional Costs Amount IV. Adjustments Amount Taxable Costs 199.80 Insurance Deductible 250.00- Sales Tax @ 8.250% 16.48 Customer Responsibility 250.00- Non-Taxable Costs 1.85 Total Additional Costs 218.13 I. Total Labor: 1;020.00 II. Total Replacement Parts: 187.15 III. Total Additional Costs: 218.13 Gross Total },425.28 ESTIMATE RECALL NUMBER: 4/10/2006108:48:49 A20500975801 UltraMate is a Trademark of Mitchell International Mitchell Data Version: MAR_OECopyright (C) 1994- 2003 Mitchell International Page 2 of 3 UltraMate Version: 5.0.214 All Rights Reserved ' Date: 4/13/2006 11:05 AM Estimate ID: A20500975801 Estimate Version: 1 Supplement: 1 (F) 4/13/2006 10:36, Preliminary FINAL Profile ID: CSAA DRN IV. Total Adjustments: 250.00- Net Total: 1,175.28 Less Original Net Total: 1,135.16 Net Supplement Amount: 40.12 SS: MARK GILLEM 40.12 THIS ESTIMATE HAS BEEN PREPARED BASED ON THE USE OF CRASH PARTS SUPPLIED BY A SOURCE OTHER THAN THE MANUFACTURER OF YOUR MOTOR VEHICLE. ANY WARRANTIES APPLICABLE TO THESE REPLACEMENT PARTS ARE PROVIDED BY THE MANUFACTURER OR DISTRIBUTOR OF THE PARTS, RATHER THAN BY THE ORIGINAL MANUFACTURER OF YOUR VEHICLE. This is a preliminary estimate. Additional changes to the'estimate may be required for the actual repair. Point(s) of Impact 4 Right Rear Side (P) Insurance Co: CSAA Address: 2055 MERIDIAN PARK BLVD. CONCORD, CA 94520-5767 Telephone: (510) 671-2708 Fax Phone: (510) 689-7939 Body Shop: Mike Rose-Via DeMercados-Conco Address: 2260 Via De Mercados Concord, CA 94520 Work Phone: (925) 689-1739 Fax Phone: (925) 689-0991 THIS ESTIMATE HAS BEEN BASED ON THE USE OF CRASH PARTS SUPPLIED BY A SOURCE OTHER THAN THE MANUFACTURER OF YOUR MOTOR VEHICLE. ANY WARRANTIES APPLICABLE +TO THESE REPLACEMENT PARTS ARE PROVIDED BY THE MANUFACTURER OR DISTRIBUTOR OF THE PARTS, RATHER THAN BY THE ORIGINAL.MANUFACTURER OF YOUR VEHICLE. Company Code: Drop Off Date: 4/10/2006 Repair Dates: Promise Date: 4/13/2006 Start Date: 4/10/2006 Completion Date: 4/13/2006 ESTIMATE RECALL NUMBER: 4/10/2006 08:48:49 A20500975801 UltraMate is a Trademark of Mitchell International Mitchell Data Version: MAR_OECopyright (C) 1994- 2003 Mitchell International Page 3 of 3 UltraMate Version: 5.0.214 All Rights Reserved i RPP-07-2006 10:02 CSRR LV2 702 897 8548 P.01 TO, Elva Bickness CLAIM: 20-5009758 FAX: 925-689-4990 From: CSAR Denisa Manone 888-582-3008 ext 7164 Number of pages including cover: 3 Please complete and send to Clerk of the Board gpy� �yy5 l`` wy'V-^Y Y3l^Y J LO cn : 1 Vit, Cz o GAJ •�•"_ `�J)Jj N�....+� Z. OCICD O t0. Z. PdOOQ m a cl o� m O Qi tn .� Cf-Y/-D t �t• .............. J h? Cn � o o� 0�4,C7roy i N� 2Wni��ro �. ddd CLAIM e . BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION: AUGUST 15, 2006 Claim Against the County, or District Governed by ) the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to } The copy of this document mailed to California Government Codes. I ) you is your notice of the action taken ENE � on your claim by the Board of Supervisors. (Paragraph IV below), JUL 18! given Pursuant to Government Code . AMOUNT: UNKNOWN COUNTY COUNSEL Section 913 and 915.4. Please note all MARTINEZ CALIF. "Warnings". CLAIMANT: TRACI GOBBELL-BROWN ATTORNEY: UNKNOWN DATE RECEIVED: JULY 18 , 2006 ADDRESS: 14 DONEGAL COURT APT. I$y DELIVERY TO CLERK ON; JULY 18 , 2006 PLEASANT HALL, CA 94523 BY MAIL POSTMARKED: JULY 179 2006 FROM: Clerk of the Board of Supervisors TO: County Counsel Ij Attached is a copy of the above-noted claim. JOHN-CULLEN, Jerk Dated.. JULY 18 , 2006 By: Deputy Il. FROM: Comity Counsel i TO: Clerk of the Board of Supervisors I ( his claim complies substantially with Sections 910 and 910.2. ( ) This Claim FAILS to c o�mply 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). O Other: 1 1 Dated: D(o I By: n1 CQ19-x..,1 Deputy County Counsel 111. FROM: Clerk of the Bo ard TO: County Counsel (1) County Administrator (2) ( ) Claim was returned asiuntimely with notice to claimant (Section 911.3). IV. ARD ORDER: By uiLnimous vote of the Supervisors present: (v�This Claim is rejected in full. O Other: 1 certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. DateCULLEN, CLERK, By Deputy Clerk WARNIN (Gov. code section 913) Subject to certain exceptions,you have only six(6)months from the date this notice was.personadly served or deposited ill the mail to file a covet action on this claim.See Government Code Section 945.6.You may seelt the advice of an attorney,of your choice in couuection with this matter: If you want to consult an attorney,you should do so nmuediately. *For Additional Warning See Reverse Side of Tliis Notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that I ant now, and at all times herein mentioned, have been a citizen of tine United States, over age 18; and that today I deposited in the United States Postal Service ill MIar(iuez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: 0&9,e�)a JOHN CUL.LEN, CLERK By Deputy Clerk BOARD OF SUPERVISORS OF CONTRA COSTA.COUV"TY INSTRUCTIONS TO CLAUVIANT A claim relating to a cause of action for death or for injury to person or fo personal property of growing crops shall be presented not later than six months after the accrual of the cause of action. A claim relating to any other cause of action shall be.presented not later than one year . after the accrual of the cause of action. (Gov. Code § 911.2.) i 3. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pie Street,Martinez,CA 94553. �. 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. I if the claim is Avair�q+ more than one puIlTic entity; separate claims must be filed against each. public entity. V E. Fraud. See penalty for fraudulent claiin+Il s, Penal Code Sec. 72 at the end of this form. ■[ll[[[[1[[l[[[[[l[ttlli[i[tl■CGitt6 t[Cttllttt[ti t C Ganz C tats tf[ttd[t t t t[l At it tl RE: Claim By: Reserved for Clerk's filing stamp I ) Against the County of Contra Costa or ) J(!L 18 2006 CLE, BOARD OF i Chll c ���I l District) CONTRACOSrpi--RL-7SORS (Fill in the name) ) A eo. i I ) The undersigned claimant hereby snakes 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 occ I? (Give exact date and hour) KNN3\, 00k Q 0(o�3 0 hA,4- 2. Where did the damage or injury occur? (Include city and county) 3. How did the damage or in occur? (Give full details;use extra paper if required) 4. t axticul�or omissiono4ni fhh�e �ai`t of coon or distnct officers, servants, or employees P P county caused the injury,or damage? 5 ( S 01� 1xvV c.�O- O�Ylp\ 2 5 �pce 3'-3O 'Sa-r Yee o What are the name of f cauhty or district o eers,servants, employees causing the' damage or injury? CO11 Go Stk W Lm 6. What damage or injuries do your claim resulted? (Give full extent of injuries or damages claimed: Attach-two estimates for auto damage,) .�G� .._. Gl S�e�� . :� Wk blown p(� I nn kni fd CGuU�S Jog -h"' vu� bbl "Q 1x lur 15 7. How was \the amount claimed above cormputed? (Include the estimated amount of any r 5�� prospective injury or damage.) Q,b5 (D n,U\(v tVT u a,( d, t 5f'IYn vw +�iron T 4m+ ha_/"J-C: -f„Kc�_ 5 tD fe�,pW-CL m - - 50 0"M Wavd�n a.n e.51Tm `P� , s� o be f 1 Ce-C� . 8. Names and addresses f witnesses, doctors, and hospit 1s: L o - 9. List the expenditures you made on account of this accident or injury: �r DATE TBJE AMOUNT asvvevsae¢aaa 9 a a aeaseaysaaaaaan■lana)aasaeaaaan¢ansanaaa¢aaaavaaasasen gamma saeaasa ai .GoI. Code Sec. 910.2 provides"The claim shall be signed by the claimant or by some person on his behalf. SEND NOTICES TO: (Attorney) 1 I Name and address of Attorney I (Claimant's Signature) > 0 } , (Address) All) 0 ( q y5a 3 Telephone No. )Teelephone N0, a a a a a a a a a an a ss a s sow a a a a a anaa a a a a a a s a a a a a a a v as a It a all¢v as aaavv a a a a a Ila a v as a v a as va v a asa al PUBLIC RECORDS NOTICE.: PIease be advised that this claim form, or any claim filed with the County under the Tort Claims Act, is subject to public disclosure under the California Public Records Act. (Gov. Code, §§ 6500 et seq.) Furthermore, any attachments,addendums, or supplements attached to the claim form, including medical records, are also subject to public disclosure, aa■a a a a a a a a a as as it a a a a a a a [ a avaavas a as Bona a a a a a Rana a a a a an as as a annual as as an n a l as a¢as a at NOTICE: Section i2 of the Penal Code provides: Every person who, with intent to defraud, presents for allowance or for payment to any state board or officer, or to any county, city, or district board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account voucher, or writing, is punishable either by imprisonment in the County jail for a period of not more than one year, by a fine of not exceeding one thousand dollars ($1,000.00), or by both such imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ($10,000),or by both such imprisomnent and fine, t Tv Z p 7 -------------------- J�N_AMEfADDRESEACc6'NTNO. -PHONE iH REFERENCE NO. 7. MPIAloyet, TT6y P,O.NO, W-PHONE DATE/TIP ;4 DOWRP-1 C"T #!I RESALE NO. .VIN NO. YEARIMAKE/MoDEL._"N.LivLICENSE NO, TAG NO. ZNEXT INSP.DATE I BAR NO. PL Y O i PROMI71)DATE/TIME E/TIME.. MILEAGE WRITTEN BY ALL PARTS NEW UNLESS N::. OTHERWISE SPECIFIED 1 ORIGINAL j REVISED I REVISED 2 I acknowledge notice and oral approval of an Increase in the original estimate price j PARTS & OTHERS n -rla' LABOR �7 91 R J-H � � 2 PIG '71 is f 3�251 :1 t 4cl,3PN", T73r) iTIN 00 VEHICLE u LF RF Wm@ GRANT BIG 0 TIRES.PERMISSION TO OPERATE THE VEHICLE J HEREIN DESCRIBED FOR THE PURPOSE OF TESTING,INSPECTINGPARTS INCLUDES REMOVAL OF WHEELS AND DRUMS FOR THE PURPOSE O F,,OF INSPECTING THE BRAKES,SERVICING,OR DELIVERY.I RELEASEO LABOR BIG'O T)RES-FRDM RESPONSIBILITY FOR LOSS OR DAMAGE TO VEHICLE OR CONTENTS THEREIN,IN.CASE OF,FIRE,THEFT OR OTHER 1 OTHER CAUSE BEYOND BIG,O TIRE'S COPqR(JUIUTHOR!Zr"THE- ILI RRREPAIR AND-SERVICE I)MIRK LISTED OW-THIS VOICE.TO BE" I SUBLET PERFORMED FOR THE AMOIUNTBHOWN..'� SUBTOTAL TAX A SIGNATURK l TOTAL ---------- C.C.AMOUNT C.C.TYPE CC.APPROVAL TYPE ON ACCOUNT yj A��AMOUNT- CHECK AMOUNT CHECK NO. THAN Y, 57-1 YOU!K 4; 1 r , r 5 �l i 2 r r y �i\ �4 lt1 CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY IBOARD ACTION: AUGUST 15, 2006 Claim Against the County, or District Governed by ) the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to ) The copy of this document mailed to California Government Codes. ) you is your notice of the action taken DID NOV on your claim by the Board of JJ,rj CSU �'J t Supervisors. (Paragraph IV below), JUL 18 2006 ! given Pursuant to Government Code Section 913 and 915.4. Please note all AMOUNT: $53. 69 COUNTY COUNSEL "Warnings". MARTINEZ CALIF. CLAIMANT. FRANCINE BEHAR ATTORNEY: UNKNOWN DATE RECEIVED: JULY 187 2006 . ADDRESS: 995 SEASCAPE CIRCLE BY DELIVERY TO CLERK ON:JULY 18, 2006 RODEO, CA 94572 J BY MAIL POSTMARKED: JULY 17 2006 FROM: Clerk of the Board of Supervisors TO: County Counsel ++ Attached is a copy of the above-noted claim. JOHN CULLE I Dated: JULY 18 , 2006 By: Deputy 11. FROM: County Counsel I T0: Clerk of the Board of pervisors . (This claim complies substantially with Sections 910 and 910.2. ( ) This Claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). O Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). O Other: JI Dated: By: ('�_ Deputy County Counsel II1. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) O Claim was returned as untimely with notice to claimant (Section 911.3). .IV. OARD ORDER: By un l nimous vote of the Supervisors present: ( This Claim is rejected in full. O Other: 1 certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: N CULLEN, CLERK, By Deputy Clerk WARM (Gov. code section 913) Subject to certain exceptions,you have only six(6)nmonths from the date this notice was personally served or deposited in the mail to lite a court action on this claim.See Government Code Section 945.6.You may seek the advice of an attorney of your choice um connection with this matter. If you want to consult an attorney,you shotdd do so inunediately. *For Additional Warming See Reverse Side of This Notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all tines herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United Slates Pos(A Service in Martinez, California, postage fully prepaid a certified copy or this Board Order and Notice (o Claimant, addressed to the claiorant as shown above. Dates IOHN CULLEN, CLERK By � Deputy Clerk BOARD:OF SUPERVISORS OF CONTRA COSTA COUNTY Q INSTRUCTIONS TO CLAIMANT �. A claim relating to a cause of action for death or for injury to person-ort personal proper=ty or growing crops shall be presented not Iater than six months after the accrual of the cause of action. A claim relating to any other cause of action shall be.presented not later than one year . after the accrual of the cause of action. (Gov. Code § 911.2.) 3. Claims must be filed with the Cleric of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine ie Street,Martinez, CA 94553. �. 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. I D. If the claim is against more than one public entity, separate claims must be filed against each. public entity. E. Fraud. Seet5' enal for fraudulent claims Penal Code Sec. 72 at the end of this form. P ■al■man as ssssss as■ssea ■■■a■as■anre•se■sas esRasa s■am a¢a e a¢a t s e ea iaa a s IN e u s s as as RE: Claim By: Reserved for Clerk-'s filing stamp Against the County of Contra Costa or ) Z7�F® t District) ccs 2006 Ry SAR (Fill in the name) } c ;,, of qA SOS ApCO b'ISpRS x> The undersigned claimant hereby des cl I against the County of Contra Costa or the above-named district in the sum of$ 53,(09( and in support of this claim represents as follows: I i 1. When did the damage or injury occur? (Give exact date and hour) # os0— t � ��I�rc►� S +rs 2. Where did the damage or injury occur? (Include city and county) Z l`�� S VF-ECT CorvT-�q CVS C� v 3. How did the damage or injury occur? (Give full details;use extra paper if required) fl '2C�C� 17 F � W( N 0 Olt 7 l V\( r�'{�l T 4. What particular act or omission on the part of county or district officers, servants, or employees caused the injury or damage? 5 What are the names of county or district officers, servants, or employees causing the damage or injury? C23- 6. 6. What damage or injuries do your clann 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 injmy or damage,) 60 Deo 1 p` e Re C-C l V3 S. Names and addresses of witnesses, doctors, and hospitals: 9. List the expenditures you made on account of this accident or injury. DATE TaIE AMOUNT oy 4m64: (ofZ(olO4 2 `{' 0-7 6 Zia /0(. ■ esaenee■caa¢ae ee es II60aCe it Cmeaae easeso eeceae Re![see serf ce'eR ea ee[e�ieesaie Kam a Ceaeee e! ) .Gov. Code Sec. 910.2 provides"The claim shall be ) signed by the claimant or by some person on his behalf." SEND NOTICES TO: (Attome-v 1 Name and address of Attorney ) L L I (Claimant's Signature) qq s S1fCJN1SC-�t�� (Address) �c� C c 2 } J T z2S IS Z2 1-53(a3 Telephone No. )Telephone No. _J�0 `� G(C� , t / U's mutunRuas&R■a Bev a as■Raa■ BEER aeesal�eesasae maBRRa ORamsa seeaesBseacaaa ear E■s a game neral I Y UBLIC RECORDS NOT ICE: Please be advised that this claim form, or any claim filed with the County under the Tort Claims Act, is subject to public disclosure under the Califomia Publir+Recgrds Act. (Gov. Code, §§ 6500 et seq.) Furthermore, any attachments, addendums, or supplements attached to the claim form, including medical records, are also subject to public disclosure. 1 E■asIus32VINN son■■■■usa■MRaX2INN eR.RRR eaa Ra Ran as R mass R a R BR Ran a Sa Bit an a am g a ass RE R R Baal NOTICE: Section iZ of the Penal Code provides: Every person who, with intent to defraud,presents for allowance or for payment to any state board or officer, or to any county, city, or district board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account voucher, or writing, is punishable either by imprisonment in the County jail for a period of not more than one year, by a fine of not exceeding one thousand dollars ($1,000.00), or by both such imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ($10,000),or by both such imprisonment and fine. A " Y p p • ° Y p Y Y ' .. p n +' Y ° ° • p Y p wy� THE COUNTY OF CONTRA COSTA MUIR STATION 1980 Muir Rd- Martine4 CA 94553 " Emergency 911 Non-Emergency(925)646-2441 WARREN E.RUPF Muir Station Business(925)313-2541 Sheriff " p • p p a EN T p C)M (y Slo(b co 20 ►� - nes i ( E0 CIA 0� '�. M�R��2 S�cJ� Y • t�N c) moo �►'� s�" n Cf� " . . *v+ sa- a �, x '.b Y > .tmvs'u q ..5 £3x `�j uY- 4 -,r�i^+ -.Fv*:,� Yx _1 :. 01,01- >+.' tr �4r #{ a g A— e Y ad am 4 1 fix- �s R'.,-, a ax s'�Aaa f iAaT*"$+'»^Y"t r } x ,« f a^r. s a a t �.X S J s v:Sx.-.:d�T>a x r £ a _n IVI�„Yy m$ _..n's ° r a..tk-. TM+ x Se..-ir � M&'"'fG' £ '� t N m $' u� 3`S mT r c 4 t 14;e td" Maj rz- g Ars ±e+r " sr" "i t' r ," I t3'p' ".RAW :ys a y�t `+4a -, J$ + p a"L vpv Fzf rn'Pe"y S aq Tf 4t +e � o, .."' r r t ;+s" rr. P5. bk. 2- a, s n i,ry�t C 4 ,sc�uw . yyx€.ra'`" msk "«ti r 5 y n rif U 3Hlf{�°��!'qu- L A, x an B�'m -3xN ¢^' € 'Ajp l J 9 Nt24 M8 �} t� M6 , dJ(e ix. t m"x fn ,y r w. 1tt y. .y+� x } ,. � : < :' r a>g r. ' tj ax wnw c "" THE NOME DEPOT 2300 NORTH PARKJBLVD %7? �e ).�yXXSDx � xu PIT75BURG, CA 94565 ((925)473-19 0 u _ ,` } �� �* L^{ q 0644 00056 6379A 06/26/,06 � i fF37� '„ _ J SALE 114 SCOT56_ 01:58 (?M� pp a f, Ac x ". �:>4" qqa a� to s ` 4 A : x� ' flm _ 937fi 3 nn, m 3�yy pit {,vu, @{� .,p e Y 4 v 5'}u2# ga :' f r fd@PSPuff[iU �' }�(T❑tSiLat?�� '�°+t + 4 x'in ry t3 �`-- e ft CL'Y�Li..p3� y ��p�J�i�" WAR { �.1 ��9 A ,S {. bxra t �,�w� e .�dn^ ,a n,� ➢ Aurc d LEN azt f°s , . � 26, t ",rr ` s, {�yAn t rc a s a x ,-.. t s 'P Y. ty i b L 5 a 3 r sas'-"' a e a t rptL.isf �t�TT �,V1t k�s ��uelu 4LiPt`C r`t r a Vj?f5 A J 07079812242O',PAINTERgPU1Y 4.29 SALES TAX Q.35 " TOTAL $4.64 L ' 4.64 ?m $effiA$ � ${ £ < xm r`✓7 3 ad ` XXXXXXXKXXXX5098 VISA 4 £� AUTH CODE 15707A/4565727; TA ✓ Y' miz f V1 0 ( f £ q Et x 4+„ryvS#kaM -.4 'Jut" 1,V0 '1111 I41111111111111119 . d,owl ydoo ar yySy � NOW HIRING SALES SPECIALISTS & DESIGNERS FT/PT APPLY TODAY IN-STORE OR ON-LINE „�t;k 1` "`_'_ - a g AT. ,t= CAREERS HOMEDEPOT COM/SALESSPECIALIST '> s:ezxrcxx,r�e>Kxx:exrc>exxxxxxxxxxxx'xxrrrcxxxv:x t ` ,+„na t£ •(t, 'C9loE"'i� 3 i ..� �,., ,y + �. �.r ax?A ;gym '" r'"�"'n r t a dsC��!'st t £ ,Ak° d A m x{uf a is;i.� 4 i td £M GG i a 3 4` t,°St p kz 2*,vrF ��a ry rls�r{ r u S 'lie s, dd x£ deSlGt �� 3 d ",� 1` it�i a% MI- r`vr ffi Y�FS $ Y vY 'x Y n0 £ £tt "CAbdY C(i ki i} ol u t n r x Lt :d7 v u .� vt-, t t t t d ♦. f ' a % <, ae aA, y f ' �+ : - a- r 5 x 4 r,euE aa✓ n ctu r 3 2 t t ' 1 E fy+a3W .. t mr n Ai aitg4r u £ v a ty"',;b a m ~M s�F i a •_ L, S$ v ,,}', S F^ s e f',Ap w C a tl .; ' *,,.,r=f mpa b aAaa ,t , r '�rr, t t rA d ££ `- ,g e =,W`cta`e"`A x ~e "da' a >p ae s a +� u t i r fsi fit ' t s r rom nn'a fn.. s n ark �n °a't ark rr sn et, a } � tr °'`y �` ror ,i ��r�i J� h &p f+ ' t A 1-1g r- egafi t L:, vJ�`sy i s s e t s F£k e rr . r rt."� --WI-Q,a#,..s ie t^,,s € r ' w 7` r `c”r t°5 s}, d o s" t o `. i $"k Mehl5 .$ E �� Too -� g ,r Ty _' �' w r S + r £ tm M r� u S a_ u '17t t} ''s 4f Sun s+ ,e':. '�` s, „p,.ro. n it A e b"1 {� x9 yre it"^'et k n 5`a, t .,An i.x:f ,mak {fd*t itdl'✓i £ a +„ 3 y t uA`� 41111c rnv -`' lVOWS TMd ills ais - t p rl*j lE �y6tj� rK a d + i11 lfilb� It l' i.'rv..t[ ,tid' SF V � _ qq �yg 3d',U4tL�t P £ s } f}is i. 1 e "t" ME NixY n �; rk x r a ae �..lows ra °>rf a r n"' tin z a , ae 1 Rol e £ sn d n 0ny, w rx :,. ,6 s• h4# a�e.m. Q � � ,{ It r'S °axc a 'f, S a3 w s M t: i C r s a s o-e d E vts • { r i so yf QW, hill a K b tr .... .,. t 1 t,7 9 l L r- tY Gl J {i CL �J i i F :t tea` 7 I r O V J lo � g LU ;10 8 � s - a< °oLLI irk t U t ��I i a � 6 �1 c t � r i r a CJ . x vi r F� I CLAIM HOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION:AUGUST lb , 2006 Claim Against the County, oi- District,Governed by ) the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to ) The copy of this document mailed to California Government Codes. D �gII� you is your notice of the action taken j,� t on your claim by the Board of JUL 19 2006 Supervisors. (Paragraph IV below), given Pursuant to Government Code AMOUNT: $50,000.00 COUNTY COUNSEL Section 913 and 915.4. Please note all MARTINEZ CALIF. ` Warnings'. CLAIMANT: PATRICK SHERMENTI #2005014272 ATTORNEY:UNKNOWN I DATE RECEIVED: JULY 19, 2006 ADDRESS: MARTINEZ DETENTION FACILIVIDEL1VERY TO CLERK ON:JULY 19, 2006 901 COURT STREET, MARTINEZ, i A 94553 BY MAIL POSTMARKED: JULY 18 , 2006 . FROM: Clerk of the Board of Supervisors TO: County Counsel I Attached is a copy of the above noted claim. JOHN CULLEN, rl Dated: JULY 19, 2006 By: Deputy C IL FROM: County Counsel TO: Clerk of the Board of Supervisors �— ( 11s claim complies substantiaywi h Sections 910 and 910.2. ( ) This Claim FAILS toIcomply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). O Claim is not timely Filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). O Other: Dated: —7'" By: _Deputy County Counsel 111 FROM: Clerk of the Board TO: County Counsel (1) County Administrator(2) ( } Claim was returnedlas untimely with notice to claimant (Section 911.3). 1V. OARD ORDER: Byunanimous vote of the Supervisors present: This Claim is rejected in full. O Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Date HN CULLEN CLERK By i Deputy Clerk WARNING (Gov. code section 913) Subject to ceilnin exception,you have only six(6)nionUts from the date this notice was personally served or deposited ill the mail to file a court action on this claim.See Gover»ntertt Code Section 945.6.You may seek the advice of nn attorney of yotu• choice in cmulection with this matter. If you.wmlt to consult tut altoi-tley,yutr should do so hiunediately. *ForAdditioutd Warning See Reverse Side of This Notice. AFFIDAVIT OF MAILING I declare under penaltylof per juiy 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 (lie United States Costal Service in Itllttrtinez, California, postage folly prepaid a certified colly of this 13oard Ostler and Notice to Clainnrnt, addressed to file claiutanl as drown above. Dated_/fro, 0&�V6 101IN CULLEN, CLERK By De.puly Clerk 17 . Claim 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 and which accrue on or before December 31, 1987, must be presented not later than the 100'b 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. (Gov't Code 911.2.) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street, Martinez, CA 94553. C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at the end of this form. RE: Claim By/me k 5-145 � Reserved for Clerk's filing stamp o2adS'o/v�7a ) /A Oil l4 tiLi'r C/o/ ceac� RECEIVED) �9, < � c �,nr- Against the County of Contra Costa or ) I U L 1 9 2006 /VuRS� y<`/ District) CLE :;E'C;.ip OF SUPERVISORS (Fill in name) tgl„D UV" '� eCSTA CO. The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named district in the sum of o vO and in support of this claim represents as follows: 1. When did the damage or injury occur? (Give exact date and hour) 2. Where did the damage or injury occur?(Include city amend county) A/9�E� O� :vod C/4/7 3. How did the damage or injury occur?(Give full details; use extra paper if reeguired) 1,�?dV alb 194.0 ~''e upv i 0 6 fl�.� sfl, ��� v�m�• /� S'G�GG�4 4,��� �A4 NaeSE HA7r+r�v'iq" wAs vEQy /Vag SSE �v DPW SECQ� l AM- 1N 14,00 sfk�.at'r�mer� .44r r Ar NA,r ROM ��df, .��✓� iJ !''vs3,vq /AJC�P� csvL rPigX s' �v Acc r -o /(+46AJaL ���'� A•vtD��,� ;o,�44. XAA0 G,���o;��v. 4. What particular act or omissionnon thepart of county or district officers, servants, or employees caused the injury or damage?IV AWIrI/yA J #f46r;PS ME 4ceft 10 M4001cF1 BARf-; sIw4 5. What are the names of county or district officers, servants, or employees causing th,�ee damage or injury? IV&jet l�/� t 1 f'`Vr� itod'� /7 ^rG�oN �i9crlif. te 6. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage.) 1''6&1' tcvoAd) 90 11id'e e®o4 Y'o'b° ro I-Actor 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) If110 APO 4- 8. Names and addresses of witnesses, doctors, and hospitals. 9. List the expenditures you made on account of this accident or injury. DATE MME AMOUNT Gov. Code Sec. 910.2 provides "The claim must be signed by the claimant or by some person on his behalf." SEND NOTICES TO: YAttomey Name and Address of Attorney ) (Claimant's Signature) Or (Address) cook r 41' R4 A0XXf 6 �4 rjf.q Telephone No. )Telephone No. NOTICE Section 72 of the Penal Code provides: Every person who,with intent to defraud,presents for allowance or the payment to any state board or officer,or to any county,city,or district board or officer,authorized to allow or pay the same if genuine,any false or fraudulent claim,bill,account, voucher,or writing,is punishable either by imprisonment in the county jail for a period of not more than one year,by,a fine of not exceeding one thousand(S 1,000),or by both such imprisonment and fine,or by imprisonment in the state prison,by a fine of not exceeding ten thousand dollars($10,000),or by both such imprisonment and fine. 0 1 O > U)%0 M �} a iL V IVl O -7, U?C�9^�. Chi 00,� N r-i O +.. to per$ ZD 00 �ca 7 z d a °}! p LL =rat Co ul l It ,t t if mo 4.1 H pit tr7 , i -44 Q `{ . x o � o u r \` 4 rn 44 r O I I r CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY . IBOARD ACTION: AUGUST 15 , 2006 Claim Against the County, or District Governed by ) the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section refet!ences are to ) The copy of this document mailed to California Government Codes. Rxgmyt youisyour notice of the action taken D on your claim by the Board of JUS 2 4 Supervisors. (Paragraph IV below), ZD06 given Pursuant to Government Code COUNTY COUNSEL Section 913 and 915.4. Please note all AMOUNT: $250.00 MARTINEZ CALIF, "Warnings". CLAIMANT: ALONZO LOGAN ATTORNEY: UNKNOWN DATE RECEIVEll: JULY 24, 2006 ADDRESS: 1337 HENLEY PARKWAY BY DELIVERY TO CLERK ON: JULY 24, 2006 PATTERSON, CA 95363 IBY MAIL POSTMARKED: HAND DELIVERED FROM: Clerk of the Board of Supervisors TO: County Counsel +J Attached is a copy of the above-noted claim. JOHN CULLEN le c Dated-. JULY 24, 2006 By: Deputy IL FROM: County Counsel f TO: Clerk of the Board of Supervisors ( "This claim complies substantially with Sections 910 and 910.2. ( ) This Claim FAILS to c Imply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). O Claim is not timely riled. IThe Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). O Other: II� f Dated: By: Deputy County Counsel 111. FROIVL Clerk of the Board TO: County Counsel (1) County Administrator(2) O Claim was returned as untimely with notice to claimant (Section 911.3). IVOARD ORDER: By u,Lnimous vote of the Supervisors present: ( ► . This Claim is rejected in full. O Other: 1 certify that this is a(true and correct copy of the Board's Order entered in its minutes for this date. I Dated. �ir4 OHN CULLEN, CLERK, By Deputy Clerk WARM (Gov. code section 913) Subject to certain exceptions,you have only six(6)mouths fi um the date this notice was personally served or deposited on the until to rile it court action on this claim.See Government Code Seclimr 945.6.You[tray seek the advice of all atlor rey of your choice or connection with this matter. if you want to consult Ml attorney,you should do so immediately. *For Additional Warning See Reverse Side of 17ris Notice. AFFIDAVIT OF MAILING 1 declare under penalty of per juiy that I ala now, and at all times herein mentioned, have been a citizen of the United siates, over age .18; and that today I deposited in the United Stales Postal Service in Alartiuez, Californio, postage felly prepaid a certified copy of this 13oord Order mad Notice lw Clainnnrt, addressed to the claimant as shown above. Dated,_ /(�°��G .10.1IN CU1-L1-N, CLERK By/7�� ':-� Depuly Clerk r' r BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT A. A claim relating to a cause of action for death or for injury to person or to personal property or growing crops shall be presented not later than six months after the accrual of the cause of action. A claim relating to any other cause of action shall be presented not later than one year after the accrual of the cause of action. (Gov. Code § 911.2..) 1 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 filhed in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. E. Fraud. See penalty for fraudulent claims,Penal Code Sec. 72 at the end of this form. •����r���������u�������r� s■ONE ■■Room mmummo■ RONNIE•room at RE: Claim/By: / Reserved for Clerk's filing stamp RECEIVED ) Against the County of Contra Costa or ) JUL 2 4 2006 District) CLERK BOARD OF SUPERVISORS (Fill in the 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$ 9S0 I and in support of this claim represents as follows: 1. When did the damage or injury! occur? (Give exact date and hour) c?C O(p 4ppPV>Z ISO 2. Where did the damage or injury occur? (Include city and county) [�1oOtcd �c9-Kt124� Ca�� �j4(�'(CEl2. •�, 1"W4C���, 3. How did the dama a or in ury occur? (Give fu details; use extra paper if required) I S ��E 'lt�� yjQqf P14cbu t oi�district officerservantTe srn�emElo ee i� 4. WhVparticular act or omission on the par y p y caused the injury or damage? 8F Rime -A LAr 5 What are the names of county or district officers, servants, or employees causing the . damage or injury? A 6. What .damage or injuries do your claim resulted? (Give frill extent of injuries or damages claimed. Attach two estimates fort auto damage.) 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.)�,7�v �y S�o� 4VkFPZ: �� S �� pUIZ(hkt5 rd 8. Names and addresses of witnessePl doctors and hospitals: lk lk I 9. List the expenditures you made on account of this accident or injury: DATE TIME AMOUNT Gov. Code Sec. 910.2 provides"The claim shall be signed by the claimant or by some person on his behalf." SEND NOTICES TO: (Attorney) Name and address of Attorney ) (Claiman ' i n e) j (Address) 9,5 Telephone No. ) Telephone No. o ` t� ,5- y3 73 pg Slv 7,3 Z19,9k ..............................J........,...................................a am own Real PUBLIC RECORDS NOTICE: Please be advised that this claim form, or any claim filed with the County under the Tort Claims Act, is subject to public disclosure under the California Public Records Act. (Gov. Code, §§ 6500 et seq.) Furthermore, any attachments, addendums, or supplements attached to the claim form, including medical records, are also subject to public disclosure. a owes Manxman on as on names a a a soon 9 0 a 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 jail for a period of not more than one year, by a fine of not exceeding one thousand dollars ($1,000.00), or by both such imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ($10,000), or by both such imprisonment and fine. V:VAS INVOICE A; 2861 f 64 E-� HA VAY .*C T% 'W ' Oc on, 1536 $WAW St kt OPEN 7 DAYS Stl(209) 466-4250 A WEEK NAME DATE /1- 22 ADDRESS CITY ZIP PHONE 0 CASH Q CHECK 13 ON ACCT. Q VISA U MASTER CARD QTY. DESCRIPTION UNIT AMT. AMOUNT --1K V, YJ C3 USED TIRE TIRE DISPOSAL C3 NO WARRANTY SUBTOTAL Z, E)NEW TIRES SALES TAX L3 VECHICLE J LABOR ,tom 0 MILES TOTAL C3 TRED WARE DEPOSIT BALANCE DUE PLEASE NOTE: G.K.TIRE&WHEELS Does not provide any warranty on used tires and will not be responsible to you or to your vehicle. WE DO NOT GUARANTEE ANY BRAND OF LUG NUTS. NO REFUNDS CUSTOMER SIGNATURE: Date White Copy-Office Yellow Copy-Customer Pink Copy-File i ..... Q� INVOICE 641 Er`CHA TEFL WY _ Stock[h, CA42861 9'206 OPEN 7 DAYS i , ; '�209� 4664250 Cot A WEEK 1 r NAME _ DATE ADDRESS CITY ZIP _ PHONE ❑CASH ❑CHECK ❑ON ACCT ❑VISA ❑ MASTER CARD QTY.jDESCRIPTION UNIT AMT AMOUNT +' r' e ty ❑ USED TIRE TIRE DISPOSAL _ ❑NO WARRANTY SUBTOTAL a ❑NEW TIRES. SALES TAX. t ~, ❑VECHICLE LABOR L)MILLS - I- TOTAL ❑TRED WARE DEPOSIT. � � a BALANCE DUE 35 I PLEASE NOTE:G.K:iTIRE&WHEELS Does not provide any warranty on used tires and will not be responsible to you or to your vehicle. ' WE DO NOT GUAR I NTEE ANY BRAND OF LUG NUTS. NO REFUNDS CUSTOMER SIGNATURE: Date White Copy-office Yellow Copy Customer Pink Copy-File C F7 � CLAIM BOARD-,OF SUPERVISORS OF CONTRA COSTA COUNTY . BOARD ACTION: AUGUST 15, 2006 Claim Against the County, or District Governed by ) the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to ) The copy of this document mailed to California Government Codes. R you is your notice of the action taken ISD on your claim by the Board of Supervisors. (Paragraph IV below), JUL 2 4 2006 given Pursuant to Government Code Section 913 and 915.4. Please note all AMOUNT: UNKNOWN COUNTY COUNSEL "Warnings". MARTINEZ CALIF. CLAIMANT: LAURA JOHNSON ATTORNEY: UNKNOWN DATE RECEIVED: JULY 24, 2006 ADDRESS: 11 BUCKEYE LANE BY DELIVERY TO CLERK ON, JULY 24, 2006 DANVILLE, CA 94526 RECEIVED FROM BY MAIL POSTMARKED: RISK MANAGEMENT FROM: Clerk of the Board of Supervisors TO: County Counsel J Attached is a copy of the above-noted claim. JOHN CULLEN, r Dated: JULY 24, 2006 By: Deputy 11. FROM: County Counsel J TO: Clerk of the Board of Supervisors ( his claim.Cbnhplies Sdbstantially with Sections 910 and 910.2. ( ) This Claim FAILS to colmply 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.iThe Clerk should return claim on ground that it was filed late and send Avarning of claimant's right to apply for leave to present a late claim (Section 911.3). ( Other: Dated: �7--Z.(,,-oBy: VVN9aB,l.--- Deputy County Counsel Ill. FROM: Clerk of the BIoard TO: County Counsel (1) County Administrator(2) O Claim was returned as untimely with notice to claimant (Section 911.3). 1V. ARD ORDER: By Laninious vote of the Supervisors present: ( 1Ol its Claun is reJecte, m rut 1. O Other: J�. I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. I Dated: HN CULLEN, CLERK, By Deputy Clerk WAItNIN �(Gov. code section 913) Subject to certain exceptions,you leave ouly six(6)months from the date this notice was personally served or deposited in the mad to Glen court action oil this claim.See Goverruueut Code Section 945.6.You may seelt the advice-of an attorney of your choice in connection with this matter, If you wmit to consult an attorney,you should do so mintediately. *For Additional Warning See Reverse Side of 171is Notice. AFFIDAVIT OF MAILING I declare under penalty of perjuiy that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 8; and that today I deposited in the United States Postal Service in Itlartiaez, Citliforuiii, postage fully prepaid a certified copy of this Board Order lord Notice to Chtiorant, addressed to the claimant as shown above. Dated JC IQHN CULLEN, CLERK I3y Deputy Clerk 07/21/06 09:06 FAX 003 BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT _ l A. A claim relating to a cause of action for death or for injury to person or to personal property or growing crops shall be presented not later than six months after the accrual of the cause of action. A claim relating to any other cause of action shall be presented not later than one year after the accrual of the cause of action. (Gov. Code § 911.2.) B. Claims must be filed with the Clerlc 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 naive of the District should be filled in. D. If the claim is against more than otie public entity, separate claims must be filed against each public entity. E. Fraud. See penalty for fraudulent cli ins, Penal Code Sec. 72 at the end of this form. •N g q q q q r q 9 0 q r r q q q q q r q q q q g q q q q a r q q It q%q N O R q q r q N r q q q q r q O q r g q q r q q q i q q■A g q e r v Zvi RE: Claim By: Reseived for Clerk's filing stamp _10 `_ -n In RECEIVED Against the &unty of Contra Costa or ) JUL 2 4 2006 District) CLERK BOARD OF SUPERVISORS (Fill in the name) J ) CONTRA COSTA CO. II ) The undersigned claimant hereby makes ilaim against the County of Contra Costa or the above-named district in the sum of$ anI in support of this claim represents as follows: 1. When did the damage or injury ocI ur? (Give exact date and hour) Iv 2. Where did the damage or injury oI cur? (Include city and county) -eixce. tkvve be6-�een ('evlay Flood_ Csm`I-rtll CVO-Avk�et OL"( hCAC .�� e Lune yUS2� 3. How did tie dime age or injury occur. ((Give full details; use extra paper if required} (vun`��' '.< �-('Icod � -CNgnCe V.A\C_h div,cfes-t1 e pAvrFts al\d '14Ae "6e�rdr� --H-\a+ o�es�iqq��c� �scvr� 4. What'particular act or omission on the part of rounV or district officers, servaiRs, or employees caused the injury or damage? 56rm/-noon w410_C5 J0 DA E4" e.f4ex_ Slo crr-i ru roof-' ti'lA C u n"{rot 1 ck McLdk-y��Qc,4,e bervn \vN lozAcev�n� r )C, el. c�vcrae�� ov��oec� �cucce�5 ova 5 What are tYie names of county or district officers, servants, or employees causing the BUcke�42 QOM damage or injury? N4 07/21/06_ 09_06 FAX Q004 6. What dainage or injuries do your claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage.) 6rm iS LEss of pc—o e�nC� —Qnotbk � reb0%�A Qnh0 reC- s-e- :t re4f-e u-?(A,)e�tvl 7. How was the amount claimed above computed? (Include the estimate amount of dfly prospective injury or damage.) t s ,-ebU tkd, +QwI P97 69vtn4-y S. Names and addresses of witnesses, doctors, and hospitals: recc s+"c45 b4im (iv)d Cu nd5 -fir- CL PexvrLer1"Vf -ice. 9. List the expenditures you made on account of this accident or injury: 4W bY1C--'AG+rL,4rDt' DATE TIME AMOUNT �-F �J be ■ amNoaa■a■NOR1100*naa.sane■ a.*samaa■►■...■ob•.■ait aaIna 01 a a a a a•■■KEA a s amp.. a a■■0a R a a•1 ) .Gov. Code Sec. 910.2 provides "The claim shall be signed by the claimant or by some person on his behalf." SEND NOTICES TO: (Attomeyl ) Name and address of Attorney ) (G&mant's Signature) RL-,r k«ti-e stn-e } I (Address) i1�711� C/Y 9�s� ) �a r Telephone No. ) Telephone No. �2 s 7 — q 33 b a .aRanaaaaaaaa............ . ..► a............a......Raaaaaaaa...aaassa.aa..a,aa.s..atook PUBLIC RECORDS NOTICE: Please be advised that this claim form, or any, claim filed with the County under the Tort Claims Act, is subject to public disclosure under the California Public Records Act. (Gov. Code, §§ 6500 et seq.) Furthermore, any attaclunents, addendums, or supplements attached to the claim form, including medical records, are also subject to public disclosure. J ■ ►no uuaus%man"amxaan.aAnxnaa a Nana a maa*$aAs&sox 9an■s.NAMED*anus*Ron a.a an a.a■aa■Ann a!1 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 exceed'uig one thousand dollars ($1,000.00), or by both such imprisonment and fine, or by imprisoiunent in the state prison, by a fine of not exceeding ten thousand dollars ($10,000), or by both such imprisomnent and fine. M•■7/21/06 09:05 FAX a001 W i 11 Buckeye Lane Danville, CA 94526 6/30/06 Maurice Shiu VIA Fax: 925-313-2333 Director of Public Works Contra Costa County 255 Glacier Drive Martinez, CA 94553 Subject: Damage from 2006 New Year's Storm and Need to Rebuild Storm Channel Berms Dear Mr. Shiu: The storm ending on December 31,2005/January 1, 2006 was centered in Danville where 4.72 inches of rain fell in a 12-hour period constituting a 50-year storm according to Mark Boucher's January 31, 2006 report. The storm resulted in an overflow of storm runoff from the storm channel into our yard and flowed through the downstream neighbors yards. The berm and,fence on the berm that separated our yard from the County's creek that crosses Diablo Road in Danville was lost during this storm due to high velocities and volume of the water. The lack of a berm to control flood water poses a safety hazard to our property and the properties of the downstream neighbors. The purpose of this communication is to submit a claim to have our fence restored and to request that the County rebuild the berm to protect our property and the downstream neighbors from future floods. On January 5, 20061 notified David Reeza, County Flood Control Supervisor, of the loss of the berm and fence. The concern expressed was related to ensuring that the County quickly moved forward to rebuild the berm to a level that would, using reasonable engineering standards,minimize the risk of having the flood control channel overflow into our yard again, David was,responsive with voice mails and indicated he had brought a County Engineer to the site to review the situation. I have yet to receive confirmation on the County's plans to restore the berm and ensure storm runoff is controlled by next year's rainy season. J I was referred to Risk Management to file a claim for the barbed wire fence that was destroyed by the overflowing storm channel onto private property. The claim is attached for reconstructing the fence. the old fence is partially buried under the soils and debris brought in from the flood and is a potential safety hazard for the children that frequently walk through the area. In the event the County is unable to immediately move forward to reconstruct the berm so my fence can be rebuilt, I am asking for funds to immediately remove the damaged fence and build a temporary fence as well as funds to build a Post-it®Fax Note 7671 Date T /D dlDpagoeso. Lf Ton From Lot-ora -1 coJDopt. 1� co, U S 1 Phone# Ph ne# c Fax 4 �,-tC_ C' Z. FmeiY + 3 07/21/06 09:06 FAX Q002 I I permanent fence once the County has constructed the infrastructure required to ensure future storm runoff will not enter the adjacent properties. I look forward to your timely response to this issue and ensuring that next year's storm runoff is maintained in the County' s storm channels. I can be reached at 928-984-4330. Thank you for your attention to this matter. Sincerely, Laura J, Johnson, P.E. Property Owner Attachment: County Claim Form Cc: Steve Lake, Town of Danville 2 CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY • �® BOARD ACTION: ADGHT 15, 2006 Claim Against the County, or District Governed by ) the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to ) The copy of this document mailed to California Government Codes. p you is your notice of the action taken + on your claim by the Board of JUL 2 4 2006 1 Supervisors. (Paragraph IV below), given Pursuant to Government Code COUNTY COUNSEL Section 913.and 915.4. Please note all AMOUNT: $3, 024. 04 MARTINEZ CALIF. "Warnings". MERCURY INSURANCE COMPANY CLAIMANT: FOR: PATRICIA EDWARDS BY : DEBORAH A. BOLMAN JULY 24 2006 ATTORNEY: Unknown DATE RECEIVED: ADDRESS: P. O. BOX 997195 BY DELIVERY TO CLERK ON: JULY 24, 2006 SACRAMENTO, CA 95899 RECEIVED FROM BY MAIL POSTMARKED: RISK MANAGEMENT FROM: Clerk of the Board of,Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JULY 245 20106 JOHN CULLEN, I Dated: I By: Deputy Z..� II. FROM: County Counsel I TO: Clerk of the Board of Supervisors This claim complies substantially with Sections 910 and 910.2. ( ) This Claim FAILS to co mply 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). O Other: I Dated: �' Z S—' �Co I By: """C!dR4 '� Deputy County Counsel 111. FROM: Clerk of the Board TO: County Counsel (1) County Administrator(2) O Claim was returned a,Is untimely with notice to claimant (Section 911.3). IV OARD ORDER: By unanimous vote of the Supervisors present: (v'� ]'his Claim is rejected in full. O Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated:, "P"Or N',7.dO49)HN CULLEN, CLERK, By Deputy Clerk WARNI (Gov. code section 9)3) Subject to certain exceptions,1you have only six(6)months from the date this notice was personally served or deposited in the mail to rile a court action on this claim.See Government Code Section 945.6.You may seek the advice of an attorney of your choice 6i connection with this matter. If you want to consult tut attorney,you should do so itrituediately. *For Additional Warning See Reverse Side of Tlris Notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that I ant now, and at all tithes herein mentioned, have been a citizen of the United States, over age I8; and that today I deposited in the United Stapes Postal Service in Martinez, California, postage fully prepaid a certified copy of'this hoard Order amid Notice to Claiauamt, addressed to the claitmt it its shown above. Dated /4 0a:46r .1011N CULLEN, CLERK By44A*�__ Depuly Clerk . 07-19-2006 02:37pm From- T-960 P.003/011 F-461 BOARD OF SUPI♦;RvisoMsFOIF CONTRA uu5Ta �;�UINI Y 'INSTRUCTIONS TO CLAIR7ANT A claim relating to a cause of action for death or for injury to person or to personal.property-or growing crops shall be presented not later than six months after the accrual of the cause of action. A claim relating to any other cause of action shall be.presented not latex than one year after the accrual of the cause of action. (Gov. Code § 911.2.) Claims must be filed with the Cleric of the Board of Supervisors at its office in Room 106, County Admiftis;ration Building, 651 Pirie Street,Martinez, CA 94553. If claim is against a district governed by the Board of Supervisors, rather than the County, the :Warne of the District should be filled in. J If the claim is againsf more than one public-entity, separate claims must-be-fd ad-against each,. public entity, I Fraud. See penalty for fraudulent claimlF Penal Code Sec. 72 at the end of this form. ee¢ggett■Ye■qee teen■ta I■e■spun i Rause HCgOgplki YBtl RE van a a tell :E; Claim By: Reserved for Clerk's filing stamp RECEIVED �� �►��ebo✓ 1 o� rM�✓► I ) JUL 2 4 2006 �gdust the County of Contra Costa or ) CLERK BOARD OFSUPERUISORS CONTRA COSTA CO. District) Fill is the name) )' The undersigned claimant hereby makes c1 'I against the County of Contra Costa or the above-named district in the sum of$ a aq . 04 and iri support of this claim represents as follows: 1. When did the damage or injury occ I (Give exact dath and hour) . �la(v�aoo to C� q :►S .ave. 2. Where did the damage or injury occur? (Include city and county) r/13 j�Uw, ' / L4V)i�)Ic.o✓lova 3. How did the damage or injury octc7ll7 (Give full details;use extra paper if required) r J �C � Vi✓[V y� - �q�r V2�t Q- vvwJ� cL u"�4C✓V� p :J I'10� yre �QA O►1Gowvrrl� 1ruP�� aVNd sW-ck our iv�SuVcr.� . 4. What"particular act or omission on the part of county or district officers, servants, or employees caused the injury or damage? ,T Vf.V- 61 yowe Vein:c lr, V 1a.� V.0 ✓e.�J on �o Ja 5 What are the names of county or district officers,servants, or employees causing the damage or injury? K Q.✓e.vi '6er8rJ Y-,o✓v) • 07'-18-2006 02:37Pm From- T-960 P.0041011 F-462 5. What damage oz injuries do your claim resulted? (Giv ll extent of injuries or damages "claimed. -Attach-two estimates for auto damage.) -! vL+n 4-Ad - 1-1 Id 7. How was the amount claimed above) computed? (Include the.gtiinated 'amount-of any prospective injury or damage;) �VVkd L la✓orn M:JP, V-0 s,e. A u-4D Bock y X H C, S. Names•and addresses of witnesses, doctors, and hospitals: ohe. 9. List the expenditures you made•on account of this accident or injury: DATE — Tra AMOUN 1 a ra11■a■■aa■■arIts rr2aaa9Nita ampler a/a2rl2a/a■apassage a■rrrR/r@rr1192/[r/■/■a R■r■■r/■2/P1 .Goll. Code Sec. 910?provides "The claim shall be signed by the claimant or by some person on his behalf." SEND NOTICES TO: (Attorney) Name and address of Attorney ) v T vow)a d004pcx 1 I (Claimant's Signature) cm (Address) R509 Telephone No. )Telephone No. (641) [A[o -_(„'i 64 u ■aaR/■■/Rea■aae■pass aod■amaa■eta■aJs/eS/rleasar■■asr■lesalsrRrr/a2asrIREo■a■rar■raru PUBLIC RECORDS NOTICE, Please be advised that this claim form, or any claim filed with the County under the Tort Claims Act,is subject to public disclosure under the California Public Records Act. (Gov. Code, §§ 6500 et seq.) Furthermore, any attachments,addeadums, or suppletaeats attached to the claim form, including medical records, are also subject to public disclosure. ■ 11le■OWN■11soa■Sell ea Salem ama■11r11■/ran■11211■■■or/Sara■rrraara■sa■are/rler.Row■r■as a■rat NOTICE: Section.73 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 fma of not exceeding one thousand dollars ($1,000.00), or by both such unprisonment and fine, or by imprisonment in the state prison, by a flue of not exceeding ten thousand dollars (S I0,000),or by both such imprisonment and fine. ON 9-2006 02:37pm From- T-960 P.005/011 F-462 i n n 0 ° Z 2oo A n Z O Om �. z � a M z ^ A . 990C x W '�. 09 'n 00 C n > N m _ 03 (IN9'K 2 > Z rvM -io G - 0 3',O zaym C ao � > -J o to m oac o mN .�'. normo s m n am`O � v W ° �M>0 y r� -i. 0 O co O te 1f; O C z � z .1 W o n �1G 0 iCl — C1 ��. � yl" A7 A 0 Fcc Q' m l cn N > CP 'G m nsn DT > cr O z C a O < 0 m L-) rr- A > o ~ O 0 -d m m in > z W 0 V T N y G C- m m N n aoO o No N r D rn gggg o x o N Ul m cn o -4 b w S n : > o V w o • uxi V 3 � N y v CD 07-19-2006 02:37pm From- T-960 P.006/011 F-462 Date: 6/21/06 02:23 PM Estimate ID: ZN002442-83 Estimate Version: 0 Committed Profile ID: Mercury Mike Rose Auto Body, Inc. 2260 Via De Mercados Concord, CA 94520-4920 IJ (925) 689-1739 Fax: (925)689-0991 Tax ID: 94-2621349 BAR #: 0969527 EPA #: CAR 000004317 Damage Assessed By: JOHN GLOYN Appraised For; MAY VANG (916) 6364534 ext, 2310 Condition Code: Good Type of Loss: Collision Date of Lass: 5/26/06 Arrival Date: 6/12/06 Payer: Insurance Deductible: 250.00 File Number: P Policy No: AP02135732 Claim Number: ZN002442-63 Insured: PATRIGIA EDWARDS Mitchell Service. 910551 Descriptlom 2006 Hyundai Sonata G15 Vehicle Production Date: 8/05 Body Style: 40 Sed Drive Train: 3.3E Irk 6 Cyl 5A FWD VIN: License: A Mileage: OEM/ALT: O Search Code: 894520 Color: SILVER "ALL CRASH PARTS ON THIS ESTIMATE ARE "NEW" ORIGINAL EQUIPMENT MANUFACTURER PARTS, UNLESS OTHERWISE SPECIFIED; PARTS DESCRIBED AS RECHROMED,RECORED,REMANUFACTORED OR, RECONDITIONED ARE CONSIDERED "REBUILT" PARTS. CRASH PARTS DESCRIBED AS "QUALITY REPLACEMENT PART" ARE NON-ORIGINAL EQUIPMENT MANUFACTURER AFTERMARIMT NEW PARTS" Line Entry Labor Line Item Part Type/ Dollar Labor CEG Item Number Type Operation DescAptlan Part Number Amount Units Unit FRONT BUMPER 1 002049 BOY OVERHAUL FRT BUMPER ASSY 2.5 # 2.5 2 002050 BDY REMOVE/REPLACE FRT ADD W/FOG LAMPS 0.3 0.3 3 000009 BOY REMOVE/REPLACE FRT BUMPER COVER 86511-3000 291.70 INC 7f 1.9T 4 REF REFINISH FRT BUMPER COVER C 2.6 2,6 5 000014 BOY REMOVEAEPLACE FRT LWR BUMPER MOULDING 86590-3K000 53.94 INC 0.3T 6 000022 BDY REMOVE/REPLACE L FRT BUMPER BRACE 86551-3K000 18.52 INC T FRONT LAMPS 7 000035 BOY REMOVE/REPLACE L FRONT COMBINATION LAMP ASSEMBLY 92101-OA000 417.84 INC 0 0,3T 8 BOY CHECKIADJUST HEADLAMPS 0,4 0.4 HOOD 9 002055 REF REFINISH HOOD UNDERSIDE 0,5• 1.4 10 000050 BOY REPAIR HOOD PANEL Existing 4,5` 1,1 11 REF REFINISH H006 OUTSIDE C 2.8 2.8 ESTIMATE RECALL NUMBER: 6/21/06 14:23:08 ZN002442-83 UhraMcte is a Trademark of Mitchell International Mitchell Data VarSlonr APi,06 V C"Pyright(C) 1994 - 2003 Mitchell Yntarnational Page 1 of 3 Ultromate Version: 5.0.215 All Rlghts Reserved 07=19-2006 02:37pm From- T-960 P.007/011 F-462 i Date: 6/21/06 02:23 PM Estimate ID: ZN002442,83 Estimate Version: 0 Committed Profile ID: Mercury FRONT FENDER 12 000206 BOY REMOVE/REPLACE L FENDER PANEL 66310-3K300 260,56 1.5 iT 2.9T 13 REF REFINISH L FENDER OUTSIDE C 1.6 2,0 14 REF REFINISH L FENDER EDGE 0.3 0.5 FRONT DOOR 15 002096 REF BLEND L FRT DOOR OUTSIDE C 0.9 2.2 16 002104 BOY REMOVE/INSTALL L FRT OTR BELT MOULDING 0.6 # 0.6 17 002106 BOY REMOVE/INSTALL L FRT DOOR MOULDING 0.2 0.2 18 002110 BDY REMOVE/dNSTALL L FRT REAR VIEW MIRROR 0.3 0.3 19 002114 BAY REMOVE/IN5TALL L FRT DOOR TRIM PANEL INC 0.4 20 002120 BOY REMOVE/INSTALL L FRT OTR DOOR HANDLE 1,2 # 1.6 MANUAL ENTRIES 21 900500 BDY" REMOVE/REPLACE LT FOGLAMP --PER INV. New 75.00" 0.3" T 22 900500 BOY" ADD'L LABOR OP COLORSAND AND BUFF ,3 PER PANEL 11.5 MAXExisring 0.9" 23 900500 BOY" AOD'L LABOR OP FLEX ADDITIVE "Qual Repl Part 8:00" 0.0" T 24 900500 BDY' ADD'L LABOR OP MASK FOR OVERSPRAY *"Qual Repl Part 10.00' 0,0' T 26 900500 BOY" ADO'L LABOR OP RESTORE CORROSION PROTECTION "Qual Repl Part 15,004 0.3" T ADDITIONAL OPERATIONS 26 REF ADD'L OPR CLEARJLOAT 2.1 27 933003 BDY' ADO'L OPR TINT COLOR 0.5" 20 ADO'L COST PAINT/MATERIALS 275.00 T 29 ADD'L COST HAZARDOUS WASTE DISPOSAL 3,00- Judgement ,00"Judgement Item # - Labor Note Applies C - Included in Clear Coot Calc Add'l Labor Sublet I, Labor Subrorals Units Rate Amount Amount Totals II. Part Replacement Summary Amount Body 13,5 63.00 '0.00 0.00 850.50 Taxable Parts 1,145,56 Refinish 11.0 63.00 0,00 0,00 693.00 Parts Adjustments 55,63- Sales Tax (1 8.250% 89.92 Non-Taxable Labor 1,543.50 Total Replacement Parts Amount 1,179.85 Labor Summary 24,5 1,543.50 M. Additional Costs Amount IV. Adjustments Amount Taxable Costs 275.00 Insurance Deductible 250,00- Sales Tax a 8.250% 22.69 Customer ResponslbilRy 250.00- Non-Taxable Costs 3.00 Total Additional Costs 300.69 I, Total Labor; 1,543,50 II. Total Replacement Ports: 1,179,85 LII, Total Additianal Costs: 300.69 Gross Total: 3,024.4 ESTIMATE RECALL NUMBER: 6/21/06 14:23:08 ZN002442-83 UltraMate is a Trademark of Mitchell International Mitchell Data Version: APR_06_Y Copyright(C) 1994 - 2003 Mitchell International Page 2 of 3 UftroMate Version: 5.0.215 All Rights Reserved OT-19-2006 02:34m From- T-960 P.008/011 F-462 I Date: 6/21/06 02:23 PM Estimate ID: ZN002442-83 Estlmvc Vcrsfon: 0 Committed Profile ID: Mercury IV. Total Adjustments: 250.00- Net Total: 2,774.04 THIS ESTIbDATE HAS BEEN PREPARED BASED ON THE USE OF CRASH PARTS SUPPLIED BY A SOURCE" OTHER THAN THE MANOSACTURER OF YOUR MOTOR VEHICLE. ANY WARRANTTES APPLICABLE TO THESE REPL%%.X1-ENT PARTS ARE PROVIDED BY THE DMMrACTURE'R OR DISTRIBUTOR OF THE PARTS, RATHER THAN BY THE ORIGINAL MANUFACTURER OF YOUR VEHICLE. Point($) of Impart 11 Left Front Corner (P) Insurance Co: MERCURY INSURANCE GROUP Address: 11150 INTERNATIONAL DRIVE SUITE#100 RANCHO CORDOVA, CA 95670 Telephone: (916)636-1534 Fox Phone: (916) 636-1597 Date vehicle driven in/ towed in: Date vehicle inspected: Date Vehicle Released: NA Date determined total loss: NA Number of photos: Estimated number of days to repair: Closing type: Send check to facility: Copy of estimate given to owner: ********CARS INSPECTION CLOSING REPORT********* LKQ PARTS AVAILABLE: NONE SOURCE: CONC AUTO DISM PHONE AND REFERENCE: 925-685-7700 Com�arry Code: _ Drop Off Date: 6/20/06 Time: 07:04 Repair Dares: Promise Date: 6/27/06 Start Date: 6/20/06 ESTIMATE RECALL NUMBER: 6/21/06 14;23:08 ZN002442-83 UltreMote is a Trademark of Mitchell International Mitchell Data Version; APR-06 V Copyright(C) 1994- 2003 Mitchell International Page 3 of 3 UltraMate Version: 5.0.215 All Rfghts Reserved 07=19-2006 02:37pm From- T-960 P.009/011 F-462 IJ tit �1-• ;�'I:S: :Irvii<r!I';L,:'..L J.'�:`x 11:;4�Mi'':�.*.hi!�1 u -I s• 1.� M.t r;t LL v 1 3 di{piiq,' rm 1 7 a ^ 1'.�y.. �ill'- �� �.• ;1. F Mike Rose's Auto Body Y/ 2260 Via De Mereados Concord CA 94520 Phone 92589-1739 Fax 925-689-0991 Claim No ZN002442-831 Adjuster MAY YANG VIN 006 Hyundai Sonata owner EDWARDS PATRICIA APPratser JOHN GLOYN o cy OfLoss 5/26/06 DRP NO i 23110 insured PATRICIA EDWARD PRELIM ESTIMATE PrinlRd with Ffl?4tmnan from Go Media.InGI 1-996.595-703-WWV-0azvimaa9-=m l is Ikk ,t•�,: -„_;ac:1 •r I •?r � I I �! IF1r•�nti(JFiI`I[\�'�''- .i 1' 1 ' ,.:I 'I ^u\n~rAr i�r �i 1� 1.i'{,. 7 If I 1 r/.,•. I � T 11 „1'1 � y 11 11 i 11 I •41.. I CVJ i �� ,ti ,! d� �,I I ��jr�Y tl( ��C •�1� r r r��?iii pl{�, I � �'� yl q•, ,���� I Ji' Ilf � jLRI( iAJAR +ul I i{tl,l�ii �'I I r I 4/05 evwp 4519 !bs + A C Iy,1111nV ��7, �m wrY .b.:U r. R AU��2 GAIVR n 513 lbs REAa 2138 lbs 'qqr IA fi 11 till Cil>, 0.$A frOfnFl I' It �'ry�ilr �rLl �1�'1!nu 'H FRGNT2 pUST APFLICASIE !dc'S 1 r(.•li�l'rl`�,� ,i�� n TGU�q.. 1/� of 11 DAN�t17EFTPAEr I' . '� 71115 YENICLEAFE7Y 6UMPEr A,11 nrnwa CNOWI! R � 1\I ' ' YENIGLfS p1F0 J 11 � x1 19 ' !IJ�f r I }^ ����/'I h1e1�IjN EFFECT ON 7pFP '1 X111 Yti,�'pVl rl{Vi('111 VI !;ISI r'�' 77a f!,'' ^`4 .p .Irl\IL.. . y Iglr g/P nN41V(,ri ro' !q[”, • .. I I i 1 ��1'1,I I I I �, 1, I' 00000 . I ly7rl I t'a^'�I rd ep .' b0 ml F,Ii00, fir, \ lel �i yl• IJ"C `4p V1 tvxlr r'u 1' 12p r �1 {S .1 r tl{1 IWpW,S 0 1 11 rqd •_2p I'LL 1111+y1 JII 1 J{r�lp� J 1: ��% C. .,1 j�`s'-�t�u 1 r!'I 1 'pnf ^ ���� 1 I:•�, W�7 1 h.Ir I I .•1" f.r� i tl.Tl 14 _ .n?rinM'WgTIC�+iftvl;,''{i lu hti C;,l,. 1 .,�I�w�• 1 yI�C'G'lT.l�} "a.,': .-.I,.'I,t•� 1 � k'1"il•• 1 'IV 07-19-2006 0238p From- T-960 P.011/011 F-462 rye' 1'I jj S21iA .,n n: r f Mike Rose's Auto Body 2260 Via De Mercados Concord CA 94520 Phone 925-689-1739 Fax 92589-0991 Clalm No ZN002442-831 Adjuster MAY VANG VIN 2005 Hyundai Sonata Owner EDWARDS PATRICIA Appralser JOHN GLOYN Po Ey D/Loss 5/26/05 DRP No 1023110 Insured PATRICIA EDWARD PRELIM ESTIMATE PrintAn with Fa IivlmTnm frnm f;n Mririia Inn. 1-996-546-7593-www,eaZvlrnaae{Gam I 07-19-2006 02:36pm From- T-960 P.002/011 F-462 AIRM]rRCl1RY INSURANCE COMPANY 74-7933 P.O. BOX 997195 SACRAMENTO CA 95899 07/18/2006 M.il.dT.: CONTRA COSTA COUNTY JRISK MGMT v 2530 ARNOLD DRIVE #140 MARTINEZ CA 94553 RECEIVED JUL 2 4 2006 YOUR FILE NO: 60742 YOUR INSURED: CLERK BOARD)OFSUPERVISORS DATE OF LOSS: 05/26/2006 CONTRA COSTA CO. OUR FILE N0: ZN002442-83 OUR INSURED: PATRICIA EDWARDS Dear PENNY BAILEY Under the terms of a policy issued to the above named insured, we have paid for damage to our insured's property in the amount of �$ 3,024.04 Our information indicates that the damage resulted from your insured's negligence. Therefore, we are expecting you to honor our subrogation claim for the above stated amount. Please return one copy of this letter with your payment. 0 Enclosed for your review is a copy of our repair bill(s) and settlement draft(s). ❑ A supplement has been received in the amount of $ and = the new total is S Our insured's version of the loss is as follows: IV GOING N/B ON BLUM. DCV S/B & MADE U-TURN IN FRONT OF IV. Please call me if you have any questions. Thank you for your cooperation. Sincerely, DEBORAH A BOLIVIAN (916) 636-1 S34 Ext 2310 C•21 04/2000 +� I CLAIM 'BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY . G�17 IBOARD ACTION: AUGUST 152 2006 Claim Against the County, or District Governed by ) the Board of Supervisors, Routi NOTICE TO CLAIMANT and Board Action. All Section r D The copy of this document mailed to California Government Codes. rJUL25 you is your notice of the action taken 2006 ) on your claim by the Board of COUNTY COUNSEL, Supervisors. (Paragraph IV below), MARTINEZ CALIF. given Pursuant to Government Code Section 913 and 915.4. Please note all AMOUNT: IN EXCESS OF $10, 000. 00 "Warnings". CLAIMANT: VIOLA GARCIA ATTORNEY: ROBERT MARTIN KISSEL DATERECEIVED: JULY 25 , 2006 ADDRESS: 1890 MORELLO AVENUE BY DELIVERY TO CLERK ON: JULY 25, 2006 PLEASANT HILL, CA. 94523 I BY MAIL POSTMARKED: JULY 202 2006 FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN CULLEN, CI c Dated: JULY 25, 2006 By: Deputy 11. FROM: County Counsel, TO: Clerk of the Board of Sup rvisors 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 Boar cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. IThe Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). O Other j� I Dated: By: /'YI Deputy County Counsel III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator(2) O Claim was returned as untimely with notice to claimant (Section 911.3). (IV. ARD ORDER: By uLnimous vote of the Supervisors present: This Claim is rejecte i in full. O Other: I cel lily that this is a true and correct copy of the Board's Order entered in its minutes for this date. Date�'d'Z/V'�.y�C1P(HN CULLEN, CLERK, By Deputy Clerk WARNl (Gov. code section 913) Subject to certain exceptions,you have only six(6)utoridis front the date this notice was persoually served or deposited ill the mail to rile Ia court action oil this claim.See Govettirnient Code Section 945.6.You may seek the advice of an attorney of your choice ill connection with this matter. If you want to consult an attorney,you should do so immediately. *For Additional Warning See Reverse Side.of Ilds Notice. AFFIDAVIT OF MAILING 1 declare [older penalty oi If perjuiy that I ant uow, 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 lNiartiuez, California, postage fully prepaid a certified copy of tlris Board Order and Notice to Claimant, addressed to the clainlant as shown above. U.-fed 16 It JOHN CULLEN, CLERK By Depuly Clerk RECEIVED ROBERT MARTIN KTSSEL JUL 2 5 ?QAP ATTORNEY AT LAW CLERK BOARD OF SUPERVISORS A PROFESSIONAL CORPORATION CONTRA COSTA CO. 1890 MORELLO AVENUE TELEPHONE(925)798-1551 PLEASANT HILL,CALIFORNIA 94523 FACSIMILE(925)682-3338 e-mail:rmkissel@comeast.net STATE BAR NO.66437 June 20, 2006 CLAIM PURSUANT TO GOVERNMENT CODE 44910 ET SEQ. Board of Supervisors Contra Costa County c/o Risk Management Division 2530 Arnold Drive, Suite 140 Martinez, CA 94553 Re: Claim of Viola Garcia USPS Certified Mail No. 7003 3110 0005 2923 4484 Claimant Viola Garcia makes the following claim: (a) The name and post office address of the Claimant is: Viola Garcia I 446 Sky Harbour Lane 1 -4 Bay Point, CA 94565 n �" (b) The post office address to which the person presenting this claim desires'notice to be sent is: Robert Martin'Kissel Attorney at Law A Professional Corporation 1890 Morello Avenue Pleasant Hill, CA 94523 (c) The date,place, and other circumstances of the occurrence or transaction which give rise to this claim are: On January 30, 2006, Claimant Viola Garcia was, while in the regular course of her employment with the State of California, transporting a light-weight file from the Superior Court's file storage building on they east side of Pine Street between Main Street and Ward Street in Martinez, California, to the A* F' F. Bray courts building on Ward Street. The sidewalk upon which Claimant was walking abutted the real property on which was situated the building that occupies the north-east corner of the intersection of Pine Street and Ward Street, Martinez, California. As Claimant walked, she stepped on or into a significant defect in the sidewalk which caused her to lose her footing and fall down onto the sidewalk. As a direct and proximate result of stepping on or into the significant defect in the sidewalk Claimant suffered injury to her right ankle and right knee and other parts of her body as yet undetermined and has further suffered great agony and pain and emotional distress, discomfort and inconvenience. Claimant also lost income as a result of the injuries she suffered. (d) The above-described circumstances amount to negligence which gives rise to an action for premises liability: i.e., a dangerous condition existing on the premises, which the public employees knew or should have known about,which was the proximate cause of injuries to the Claimant. Claimant has suffered physical injury,physical pain and agony, loss of income and emotional distress. The extent of damages to which Claimant is entitled due to the enumerated losses is presently unknown,but is in excess of$10,000.00. (e) The name or names of the public employee or employees responsible for causing the injury, damage and loss are not known at the present time. (f) Jurisdiction of this claim rests in the Superior Court. Very truly yours, Robert Martin Kissel Attorney for Claimant Viola Garcia Page 2 c i f M I � Q5 kn 0 lod4. m ru, Er C3 M 1 M o m m S ®, P 0 p. r- odU d � Vaa" 0 a oho a Chi Q G, ƒ : � . . , . . . . � a « � u � M : / \ A » 6 J � • Z 4 3 ? k \ , \ § oQ . 4.4 3 �_ cn� � « \ � i� � . - M§ { ? . # kik \ CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY L f IBOARD ACTION: AUGUST 15, 2006 Claim Against the County, or District Governed by ) the Board of Supervisors, Routitig Etidorsemeuts, ) NOTICE TO CLAIMANT and Board Action. All Section refe Di '-wa dfA The copy of this document mailed to California Government Codes. LL�y �7=�� Ll°//AM you is your notice of the action taken. JUL 2 5 2006 on your claim by the Board of Supervisors. (Paragraph IV below), COUNTY COUNSEL given Pursuant to Government Code MARTINEZ CALIF. AMOUNT: NEGOTIATION (UNKNOWN) Section and 915.4. Please note all "Warnings". CLAIMANT: BRENDA JOYCE GARDNER ATTORNEY: UNKNOWN DATE RECEIVED: JULY 25, 2006 ADDRESS: 1590 FRISBI+E COURT, BY DELIVERY TO CLERK ON: JULY 25 , 2006 APT. #6 CONCORD, CAA 94520 BY MAIL POSTMARKED: JULY 24, 2006 f FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN CULLEN, CIpr Dated: JULY 25, 2006 By: Deputy I1. FROM: County Counsel I TO: Clerk of the Board of Supervisors ( �. es substantially `This claim with Sections 910 and 910.2, ( ) This Claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). O Claim is not timely liledil The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( k OttlIter: )1Dyr CI41r'r, /$ �j�y,z.�y Or1��/ D/ L'r�e/1 OGGU✓Y/yG �/� QY�'^ dt -fir" ...74nog'N Z/I;Z.OD6 A4 Clliow5 �l- ��1�3 ar_cwrr/nw �7Grt— a�ra. 2`/, 2o0b 4rt ri.d/amu/.e- an,4020 ahM: �,t- g4 dalOt Dated: 7—2-fe— , By: Deputy County Counsel III- FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) O Claim was returned as untimely with notice to claimant (Section 911.3). (1V. ARD ORDER: By 11unanirnous vote of the Supervisors present: This Claim is rejected to full. O Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: «c V $DHJN CULLEN, CLERK, By Deputy Clerk WARNIN (Gov. code section 913) Subject to certain exceptions,you have only six(6)months from the date this notice was personally served or deposited ill the diad to rile a court action on this claim.See Govemment Code Section 945.6.You nray seek the advice of an attorney of your choice in connection with this rtratter. If you want to consult au attoiiiey,you should do so qImnediately. *For Additional Warning See Reverse Side of'Ilris Notice. AFFIDAVIT OF MAILING 1 declare under Penalty of per juiy that I and now, and at all times herein mentioned, have been it citizen of the United States, over age IS; and that today I deposited in the United States Postal Service iu�Mal tinez,,Califoruia, postage hilly prepaid a certified copy or this Board Order mid [Notice to Claiui:nit, addressed to the claimant as shown_above. Date101IN.CULI-EN, CLEKK By Uepuly Clerk o OFFICE OF THE COUNTY COUNSEL S. SILVANO B.MARCHESI COUNTY OF CONTRA COSTA + -" - _�O� COUNTY COUNSEL Administration Building _ ` 651 Pine Street,9"' Floor SHARON L. /ANDERSON" i � `�;° CHIEF ASSISTANT Martinez, California 94553-1229 - - ' a (925) 335-1800 GREGORY C. HARVEY i;ai0\� Q. �/ VALERIE J. RANCHE (925) 646-1078 (fax) , o AssisTANTs �CSrA COUIZ� NOTiICE OF UNTIMELINESS AS TO A PORTION OF THE CLAIM TO: Brenda Joyce Gardner 1590 Frisbie Court, Apt. 46 Concord, CA 94520 Please Take Notice as Follows: In regards to the claim you submitted on July 24, 2006 , portions of your claim are timely and portions are untimely. The portions of your claim prior to January 24, 2006, that you presented against the County of Contra Costa governed by the Board of Supervisors fail to comply substantially with the requirements of California Government Code Sections 901 and 911.2, because they were not presented within six months after the event or occurrence as provided by law. Because the portions of the claim prior to January 24, 2006 were not presented within the time allowed by law, no action was taken on those portions of your claim. The claim was forwarded to the Board for action only on the timely portions of the claims. J Your only recourse at this time is to apply without delay to the County of Contra Costa governed by the Board of Supervisors for leave to present a late claim as to the claims which are untimely. See Sections 911.4 to 912.2, inclusive, and Section 946.6 of the Government Code. Under some circumstances, leave to present a late claim will be granted. See Section 911.6 of the Government Code. You may seek the advice ofan attorney of your choice in connection with this matter. If you desire to consult an attorney,you should do so immediately. SILVANO B. MARCHESI COUNTY COUNSEL By: ktivxl,, Monika L. Cooper Deputy County Counsel Brenda Joyce Gardner Re: Claim Page Two CERTIFICATE OF SERVICE BY MAIL (Code Civ. Proc., §§ 1012, 1013a, 2015.5; Evid. Code, §§ 641, 664) I am a resident of the State of California, ler the age of eighteen years, and not a party to the within action. My business addres is Office of the County Counsel, 651 Pine Street, 9th Floor, Martinez, CA 94553-1229. On 7'2 7 ZD , I served a true copy of this Notice of Untimeliness as to a Portion of the Claim by placing the document in a sealed envelope with postage thereon fully prepaid, in the United States mail at Martinez, California addressed to Brenda Joyce Gardner, 1590 Frisbie Court, Apt. 46, Concord, CA 94520, as set forth above. I am readily familiar with Office of County Counsel's practice of collection and processing of correspondence for mailing. Under that practice, it would be deposited with the U.S. Postal Service on that same day with postage thereon fully prepaid in the ordinary course of business. I declare under penalty of perjury under the la of the State of California and the United States of America that the above is true and correct. Executed on� 2--"7 'Z- D 46' , at Martinez, California. Ktathleen O'Connell cc: Clerk of the Board of Supervisors(original) Risk Management BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT A. A claim relating to a cause of action for death or for injuryto person or to personal property or growing crops shall be presented) not later than six months after the accrual of the cause of action. A claim relating to any other cause of action shall'be presented not later than one year, after the accrual of the cause of action. (Gov. Code § 911.2.) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street, Martinez, CA 94553. C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District,should be filled- in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. s,. E. Fraud. See penalty for fraudulent,claims;Penal Code Sec. 72 at the end of this form. Claim Bim. Reserved for Clerk's filing stamp k 0 n- a "d �V =I ECEIVED 'Ag ir)st e Co t3 of tr to ) J U L 2 5 .2006 G(� 1� r /p� !! ••..S��uNc � V S -- CLERK BOARD OFSUPERVISORS Disttic �,, CONTRA COSTA Co. (Fill in the name) 6 / �JgIZI The undersigned claimant he eb makes I laim 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. Whe did the damage or injury occur? (Give exact date and hour) kv-vclk out, 2. Where did the aB damage or,injury o cur? (Include city and county) 3^ 3. How did the damage or injury occur. (Give full details; use extra paper if required) 4. What particular act or omission on theart of county or district officers, sere s, or employees caused e injury or daaage? p (.0 Y ` - C 5 What are the names of county or district officers, servants, or employees causing the damage or injury? SkA4 l... ' w tjov IV fir 6L tit t �J i r s4 '� d�MA! c► � ? 'z A k.c.k l�6' Luh ? ktl X A 6,- oft� 90 kXA.4'A k4� 4 , PIA tj o -lpws 4At.,, - �U ,' PL a nit . 4h1-j d, M LAZ Sass -c � C/a �✓ (( L, yp �j-�'j -� (� /' t✓'�„` W r te' "" _ I Q�{J tu LA-tp 4v* > tN 'F� M FA A 61d A4�zLi jam j � '1 , ixg J-4 1A. LA)o Y1 � s /W4 itis °� �, Alt ,� r pts A- 1',COTL 44 LA) 6. What damage or injuries do your claim resulted? (Give full extent of injuries or da/mages claimed. Attach two estimates for auto' damage.) aewi'J IL • �l '1 n ` � �f `P/�],r" w n �ilu��.�,/( 1 J�, K rnl Oa e" -the esti ed ount tf any pros ective injury or damage.) ,� � w i A � 8. Names and addresses of witnesses, doc ors, and ospitals: .o "I- 9. List the expenditures you made on account of this accident or injury: DATE+ a T,M'E$ '' . Z, AM iJNT , ' I ' , 1 ,•A, 'Y;N l �j�1�. W �G'. -}� '�-'-'•��� VV��t •�!"i� ■I IR�mI/I -I■ Ildmm I ve/IIe//R ev.e'v1omrs 1112101k .av/as'vevvvvaaammmaaImly e■ i v C Gov. Code Sec. 910.2 provides "The claim shall be)'signed'-by`n ` the-claiinant or b' dsome person on his behalf. SEND NOTICES TO: Attome t ` ° ' q• ` "4 Name,and address of Attorney ant's Signs e), } i i / j • � ) � 1p (Address) , Telepl one No. a: ,A ! �) Telephone,N(,, /_U,/ r7 ■IIIaNI"%1%1/a/1I�RIf,I1■/II'/I'/411I11Ri II1■�I/II11.1IIIIIII■III■//am/IIaI■II I)��I�I1I aI//a'I ' PUBLIC RECORDS NOTICE: 1-' it Please be advised that this claim form, or any claim filed with the.County�under the Tort Claims Act, is subject to 1 t public-disclosure under the California Public Records Act: (Gov.-Code, §§ 6500 'et seq.) Furthermore, any attachments,adderidums, or supplements attached to the claim form, including medical records, are also subject to public disclosure. ` C j ; IIIIi IIm/I�rIII/II I IN IIIIII II I�IAi�/Ii/�/v/ImI SIII}IVII W.I,I I mo MiI� ,m1m M:�,I I a 0 NU a M %no ma m i' ' NOTICE: ; i Section 72ofthe Penal Code provides' t a 1 Every person who, with intent to defraud, presents fWallowance or for payment to any state board or r officer, or y 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 imprisontnem,in the County jail for a period,of not more than one year`;'by afine of not exceeding one thousand dollars ($1,000.00), or by both such imprisonment and fine,,or by imprisonment in the state prison,by a`Fine of not exceeding ten thousand dollars ($10,000);for by both such iniprisonment,pnd fine. 1 �t '• 1 5.. i. ,�f.r , 1 bv 1 - � U I i N "rued Resourt" WA 815 25800 Ca Bae Blvd Hayward,C 94542 TPil hone 5`10188 °Fax 810 8 •2951 o Emplo 1711ness 's Repoli f ork Injury tA{BTRU t u or illness complete;and return form Human R you mu s. of,yow medical status to t , .In a(�M)hours of he injury r>bse by treatng med rovider. You must submit a Y 2,;. ntlthus your medical trnatmsnt as Press HurnanResouross `\�� d Date of B Name Home Address:LONumber t& Street /40 Home Phone`l S_ eDft `-Z �s , 1 nn j�;-bnfi le f, � ; i � C„ •Departmen{� ,r ra�k�. ,�pv �pervies Name " DOW and Tune of Acddentllnjury or Onset of Il ss R t of Week and nth/D9W- ee an yvork -4Last Day Worked( am Pm Time Employ seg an Tues Wed Thu Fri Sat bun rk iohedulem I m Work daYU: , LNE88. DODIV _ Cdun Location of gcc*dant Ctty . �D (� ddress 3 Build � a. • ��r�SQ a�'Tllrle Aceid � ' Accide potted yw Part(O of tl» I lure fi > Ves i.. Did injuryAllness *suit in First Aid? No d r - — Was an outside agencylpewn responsible? No Yes N so;who? Were other employees injure ? Yes fNg If. es who?> Qi 1 �-. Nome(S)of WiNess(es) s y GI Sr b Describe how the accidentlinjurytneaslneas o� L r fJ1 VI i • 2 x � w \ �� Whet acllQn ears b0 taken rt: y to°Preyentt this, f inJu 1a Employs s81p wk �x :•. 4 § , ; u i of dhtakdnp Workers' Nora: It la a tslaiy ror an to Iib a tales or fiauduledt statemerd orxto aubmk a rePo}t or arty other document P aqs vAA t3tls fup extent of the law. If th On=Could faoe up to ComMn�!beneft. Antons eaWht De ming these ile0a " oblos 6 Years in pin endlor s fine up tosft50 000: uvkvuC ���\f e N O d Ott wt i �t1 � t�y � tt} C , F � � yq V) »O (!y nT LLSp cr J `CM r W --D my r -- ,:,i IN TIMM ti 1` � CLAIM BOARll OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION: AUGUST 15 , 2006 Claim Against the County, or District Governed by the Board o€Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to ) The copy of this document mailed to California Government Codes. you is your notice of the action taken D tj , on your claim by the Board of JUL 2 6 2006 Supervisors. (Paragraph IV below), given Pursuant to Government Code COUNTY COUNSEL Section 913 and 915.4, Please note all AMOUNT: $250.00 I MARTINEZ CALIF. "Warnings". CLAIMANT: BRENDA HANSCHEN ATTORNEY: UNKNOWN DATE RECEIVED: JULY 26, 2006 ADDRESS: 12 CREST VIEW TERRACE BY DELIVERY TO CLERK ON: JULY 26, 2006 ORINDA, CA 94563 JBY MAIL POSTMARKED: JULY 25 , 2006 FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN CULLEN, r t Dated:, JULY 26 , 2006 By: Deputy Il. FROM: County Counsel TO: Clerk of the Board of Supervisor^ s ( lis claim connplies.substantially with Sections 910 and 910.2. ( ) This Claim FAILS to c�mply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). O Clain) is not tinnely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). O Other: I Dated: �' Y'�� I By: 4 Deputy County Counsel 111. FROM: Clerk of the Board TO: County Counsel (1) County Administrator(2) O Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By Inaniinous vote of the Supervisors present: (t,�' This Claim is rejected to full. O Other: I certify that this is I true and correct copy of the Board's Order entered in its minutes for this date. I Dated )OHN CULLEN, CLERK, By Deputy Clerk WA1 NIN (Gov. code section 913) Subject to certain exceptions I you have only six(6)months from the dale this notice was personally served or deposited in the mail to rile a court action on this claim.See Govenunent Code Section 945.6.You may seek the advice of an atiorney of your choice in connection with this matter. If you WMA to consult tut attorney,you should do so n0luediately. *For Additional Warning See Reverse Side of Tltis Notice. AFFIDAVIT OF MAILING 1 declare under penalty of perjury that I ain now, and at all times herein mentioned, have been a citizen of the UI>>ited States, over age (8; and that today I deposited in the United States Postal gen ice in Martinez, Califorttia, postage fully prepaid a certified copy of this lWai d Order nod Notice[ to Clninuutt, addressed to the cl:uolant as shown above. Dated �/ 4�6 .10.1IN CULLEN, CLERK l3y Deputy Clerk BOARD OF SUPERVIsoi,6 OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAMANT i. A claim relating to a cause of action fo� death or for injury to person or to personal property or growing crops shall be presented not later than six months after the accrual of the cause of action. A claim relating to any other cause of action shall be.-presented not later than one year . after the accrual of the cause of action. (Gov. Code § 91.1.2:) 3` Claims must be filed with the Cleric of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street,Martinez, CA 94553. If claim is against a district governed by the Board of Supervisors, rather than the CountSr, the :name of the District should be filled in. D. If the claim is against gore 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. ft aafaa Ra[aaf a[afai t t R a R f Ra R R f an ifs RCa a ff aaaaf Raw f a R¢f f 06 Ina at■am a s al a s afa i s al RE: Claiiii'13p; Reserved for Clerk's filing stamp RECEIVED Against the County of Contra Costa or ) JUL 2 6 2006 District) CLERK BOARD OF SUPERVISORS (Fill in the name) CONTRA COSTA G0. I ) The undersigned claimant hereby makes cll against the County of Contra Costa or the above-named district in the sum of �.5 ,,00 and in support of this claim represents as follows:- 1. When did the damage or injury occur? (Give exact date and hour) JLL y 11, ��n� � � r� OLM . 2. Where did the damage or in ,occur? clude city and count ) Near Ct�ee(�. 60A rbt,16VICS vq" �. How did the damage br injury occur? (Give full details;use extra paper if required) _C� tl.)D S C�►r i "lid � 4. - Wbat' articular act or omission on � b��t � �S 't-"'�S t >1� . a VA l the .. ..o p th6art of county or district officers, servants, or employees caused the injury or damage? 5 What are the names of county or district officers, servants, or employees causing the damage or injury? p Jae I }— Qt C Oh ev Lkr Fl damage or injuries do your claim resulted? (Give full extent of injuries or damagescatmed ,Attach-two estimates-for auto damage.) SS- U A-Y-) W D,54ro vv� t�'r�-L-� � pb 1 ae A c �-�- -�-o .�act o v rt h-t- 5 i cl-e 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injtuy or damage.) + ��$ Gni 10.YCJ erg 1 2-SO 6yy CI�LY t�C�S (n A ►rtVA ax . 2 had beer-) e�,►l �a ► l e �-� bey 3k 0)0 �-f n ece�S�.r 8. ales an addresses of wi esses, doctors, and hospita s: 9. List the expenditures you made o�unt of this accident or injury: DATE TIME AMOUNT ft/c a9amaago■asaaalaaaamaaits amaaaaaaatasaa/now as asa/aaaaa/an a a aaa as aaa&%%aaaaa/aaa[aas0aI .Gots. Code Sec. 910.2 provides"The claim shall be signed by the claimant or by some person on his behalf." SEND NOTICES TO: (Attornev) 1 Name and address of Attorney ) (Claimant's Signature) (Address) .No Telephone ) p ) Telephone ATo. ap■own Krug cats/a tar aas roam a[a:aa llaa/0aa anal rataata/Known aaa saaaaa[a■la■ata 992 as 991 PUBLIC RECORDS NOTICE: Please be advised that this claim form, or any claim filed with the County under the Tort Claims Act, is subject to public disclosure under the California Public Records Act. (Gov. Code, §§ 6500 et seq.) Furthermore, any attachments,addendums, or supplements attached to the claim form, including medical records, are also subject to public disclosure, aaaaa■ac//[a[tfa[[aaif/as ■ af[f afi aaafaafaaa■gas[i[[[[faf■[ta[f[a/c[[aa aaa aaa as aft as all NOTICE: Section 72 of the Penal Code provides: Everyperson who, with intent to defraud, presents for allowance or for payment to any state board or officer, or to any county, city, or district board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account voucher, or writing, is punishable either by imprisonment in the County jail for a period of not more than one year, by a fine of not exceeding one thousand dollars ($1,000.00), or by both such imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ($10,000),or by both such imprisorunent!and fine. ° Customer Name '(-k C t 1 !;i ,� 1�C o A F A Y E CT T E o `�Job Date o° Home Address : yC ( /. Lto "k d t 1", o City F' i t �-I r'!L t .�° Zip &DETAIL CENtl , Phone# Time I & lL' 3319 Mount Diablo Blvd. pp 77 tt (925) 283-1190 Make of Gar kkj&Condition Year Mode1, ,U kt}Color .`' i Gt<.✓ ' t ......r Salesperson Estimate$ ❑ Original Paint ❑Repaint I SERVICE PRICE. n ❑ Limited Warranty Months �12-Exterior-Services: f f� Dealer Comments: / Interior Services: { Engine Clean: Fabric Protection: E]Extra Services: i Engine Cleaning: Lafayette Car Wash will not be responsible for damage to an electrical system due to engine cleaning. Customer Signature: Subtotal Tax TOTAL- ✓ - �'_ I I + i ,. Y�.•1�...a-w`,. a �, "-: L `,��r�..oC�..•-u..,.zk",f,...,..,-+.. .r -.rr-;i''.W'' ,� �".r'.,.t .. * F A Y E T eo Customer NameJob Date 00 #Home Address t ; ` "+` i r t t t ' ; lk o City I k s Ik. t Zip r &®ETAIL CENT It r u-...� N Phone# * .:.< l Time �,;p19 Mount Diablo Blvd. I (925) 283-1190 Make of Car t'i;. J&6o"ndition Year Modell ,t,. :`. [Color � t Salesperson -" Estimate$ Original Paint ❑Repaint i SERVICE "' PRICE , s E—Exterior Services: Limited Warranty Months ..-^- Dealer Comments: - E],Interior Services: J0 Engine Clean: Q Fabric Protection: E]Extra Services: Engine Cleaning: Lafayette Car Wash will not be responsible for damage to an electrical system due to engine cleaning. Customer Signature:. Subtotal Tax 7' {; TOTAL. ` I LAFA'f CAR tAsa 3319 MT. DIABLO BLVD F ADURESS'L LAFAYETTE, CA 94S49 - 925-2'AS-1156 N hrrghect ID: 573106045HGb Term ID: 061 Ref n: 313 Sale VISm crltrY Ntk S-ik ?% V9:1?: 1 Iri; '0: NVNI3 nPPr Cod- MKIN q�p ud: Oali�E 9atzh�: 2101 1o� I: Customer Con's THANK YOW! PLEASE COME AGAIN N JobDate,,Customer Name 1 Lt� I l ► ' A VA-Y-E` � T <` 6 o0 " `:}"Home Addeess v— I Q Zip &DET/d►IL^CENT 3319 Mount Diablo Bivdv �` Phone# ` : 4 Time �, a (925) 283 1190 Make'of Car l C�bndihon Year' Model ,Ltd t" Color �tl� � r - . b Salesperson, - E"stlmate v ^ ,Original Paint"Repaint` 1 ��'. �' � �� SERVICE PRICE, CXIe ibr,r§diviq Limited Warranty Months 9 3 � ti r t .� - Dealer, oinhlents` `� []Intenof Services x 77 y"ji �w�✓ s i.,,atax Sd°7- `� z t :� r 3 i 4 )t' x c i` r Fis�w.�.. a} ai rJx x x Y u nl i» a Efigln2gC�8an r d 4 s m , s ' ,+ �,x( _ 7�FabriG'PrOt6Ct10�1 " ,f "'J' (A �pk i n i ,Y y� fr ^'*i ti. +._i..'Lkl..l�*' Lid. ..SeNICBS 'r " s x a f �'''* y '1R4 a4 J�•et)!MC-s ,m a y- 1k S .� 1 4 ti ST I ] E iC'r-� T i 4r tai 1F '� s 7 ; P s tti .. 3 rl �. `w •t v y 4ny' k FS {F((,, 3 Y.l `S3tJ` lifis x t#•' 4 t.n '�� {t y M 3 { t 1 } r,,.ti �` t✓ k- N �, .tie .� i F 7 f y Engine,Cleaning Lafayette Car Wash',will not be responsible a<r ,h,�;:Yr _ , � ,_,� , � ;s'� _•. �' �; �f P ^ for,damage to an electrical system'edW&e'to;engine fcieaning lei L «r 'S i mkt k n �3 ! k� na �xx ext{ tM ' {t yk nSii e 'i•R N 43 f y ," �,� r 31�ju�tomer Signature r •' 3 S t � f z.+F v e , ^� $ 4 x 4.5 6 e� �,r F ;A' c .:L. ✓ 7� "� ,$-.u.!.....}.w b,uv.L1 c�L�u �..�... '1�'�� ��.-Lm.,A-+„���n..i.�.G."..�iu�w�; w {�W�S_va�:i:..n,.:".`r..:�ra1L'3'.��.�.i.�..�.x..':a:t:�;i�.n ��h�:.`Y .b �«-�wG •^' t�.,�v'.^.F�3a .`i�.M�'�„� D;.a.�,9Y AfnT'.�.�,��a.s.i,.�u.k..L& LAFAYETTE CAR WASH 3319 MT. DIABLD BLVD ADDRESS2 LAFAYETTE, CA 94549 925-283-1190 Merchant ID: 510100045060 Term 10: 001 Ref 9: 013 Sale XXXXXXXXXXXX0150 VISR Entry 11ethad: Swiped 01�20�6 09;47,31 Inv 000013 4pr Coda, 029101 Oprvd; Online. htrha, 201001 Total, 3 250,44 Customer Copy THAM/ YOW! PLEASE COME AVAIW 't Alf s J � Cfn r 5F t 1 r r v LO d v u OPP 00 U ,s , /� c � ,. .-� ... .,1,. r�ili �� •, ,.� �� ^�, r J,� � ; �, � {� c� tt L �1 .-' � � .»� r �� � '""� \` = .. 4 � Y"' (` /� } li� V�� � � r '' '�' �� *� � � � . -� �� � �� ry �� � �� E_ ,_., ;... � ��� .� �, .�,5 �: �. � 1,,e �, ,� � � ,�ti 1 � __.- � �. �' c.�. � � o N .. � � � �� �� � � O� &e"^ Ery `. �� ��� � � �t�,.1 �.� � '� d O� V„ tai d.L, �� V N ��.� � � �� �� �u CLAIM BOARD OF SJUPERVISORS OF CONTRA COSTA COUNTY (.® • `�v�� BOARD ACTION. AUGUST 15 , 2006 Claim Against the County, or District Governed by ) the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to ) The copy of this document mailed to California Government Codes. ) you is your notice of the action taken on your claim by the Board of CLAIM AGAINST CCC OR rvisors. (Paragraph IV below), THE HOUSING AUTHORITY OF CCC D (�rnv i Pursuant to Government Code ll�� t1 L/ n 913 and 915.4. Please note all AN101IN"f: UNKNQWN JUL 2 7 200 sings". CLAIMANT: KENNETH PARMELE COUNTY COUNSEL MARTINEZ CALIF. ATTORNEY: UNKNOWN DATE RECEIVED: JUDY 37-, 3006 ADDRESS: 15 SEQUOIA CAVE BY DELIVERY TO CLERK ON: JULY 27 ,. 2006 WALNUT CREEK, CA 94595 BY MAIL POSTMARKED: JULY 253 2006 FROM: Clerk of the Board of (Supervisors TO: County Counsel I Attached is a copy of the above-noted claim. JOHN CULLEN, ger Dated: JULY 279 2006 By: Deputy It. FROM: County Counsel + TO: Clerk of the Board of Supervisors. ( 0-'Tliis claini 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). O Other: 1 Dated: By: MCAs —Deputy County Counsel 111. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) O Claim was returned as untimely with notice to claimant (Section 911.3). WOARD ORDER: By unanimous vote of the Supervisors present: This Claim is iejected in full. O Other. 1 certify that this is I true and correct copy of the Board's Order entered in its minutes for this date. Dated �C!" �N CULLEN, CLERK, $y Deputy Clerk WARNI (Gov. code section. 913) Subject to certain exceptions you have only six(6)niontlis from the date this notice was personally served or deposited hi the intil to file a court action on this cWui.See Government Code Section 945.6.You niay seek the advice of au attorney of your choice 6i counection with this matter. If you want to consult au attorney,you should do so uiunediately. *For Additional Warning See Reverse Side of Tliis Notice. AFFIDAVIT OF MAILING I declare under penalty lof perjury that I ail now, and at all blues herein mentioned, have been a citizen of the United States, over age IS; and that today I deposited ii the United States Post d Service ill IMal tinez, California, postage fully prepaid a certified copy of this 139ai d Order and Notice to Claim:uit, addressed to.the claimant ns shown above. Dated: /6 CeWe JOHN CULLEN, CLERK By Depuly Clerk Claim to: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT_F7 f A. Claims relating to causes of action for death or for injury to person or to personal property or growing crops and which accrue on or before December 31, 1987, must be presented not later than the 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 bei presented not later than one year after the accrual of the cause ofaction. (Govt. Code §911.2.) B. Claims must be filed with the Clerk of the Board of Supervisors at its 0 fice (aEIVE® Room 106, County Administration Building, 651 Pine Street, Martinez A 94553, either by mail or in person. JUL 2 7 2006 C. If claim is against a district governed by the Board of Supervisors, rather th IK BOARD OF SUPERVISORS CONTRA COSTA CO. 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 Kenneth Parmele r� Against the County of Contra Costa f {, r� or / /% r 0� T �l y Jr- GHAflfo;�tl The Housing Authority of Contra Costa (District) (Fill in name) The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District in tlIelsum of and in support of this claim represents as follows: i/OM ,1-1;1�710 1. When did the dam- or idjury occur? (Give exact date and hour) 2. Where did the damage it injury occur? nclude city and county) // f,� 3. I-low dfd the daO ge or'injury occur? (Give full details; use extra paper if required) /c?a�� /(f/ 4. What particular act or om' ion on the part of county or istnc officers servants or employees caused the in�ury or damage? clmform , 1./"� ' t [� ' ��h �r � / /(/'�e /JJV•r� C,.(f t/ r�� [.� /�I ( ' 5. What are the names of county or district officers, servants or employees causing the damage or injury9 /?1-1111d. r b. What damage injuries cTo you claim resulted? (Give full extent of injuries or damages claimed. Attached two h estimates for auto damage.) G �' e 0 7. How was the amount claime above computedV, e th stimated amoult of any prospective injury or damage.) YeeC���i�li%�-� �1` I/t/�/��✓`r/f/PG �/�•� l/�� l�j•GGC-- 8. Names and addresses of witnesses, doctors ana hospit s. i List the expenditures you made on ac ount of this acci ent or injury: �_[I DATE ITEM AMOUNT /:„�� IPA$,, J” 0� G„"f'(- li oc,4 C1i�- l V SS7 aG 7 05 Gov. Code Sec. 910.2 provides: "The claim must be signed by the claimant SEND NOTICE TO: (Attorney) or by some person on his behalf" Name and Address of Attorney (Claimant's Signatti7re) ( ddress Telephone No. Telephone No. NOTICE Section 72 of the Penal Code provides: "Every person who, Iith intent to defraud,presents for allowance or for payment to any state board or officer,Jor 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." clmform % @lit � % � \ cr ��! » k � LO &Vq \ ® � ) 3 ¢ r � . ± 4 A \ D ƒ $ . . � � - § � . � $ f -t o \ 0 % -7, a « . CD k Q \ � � 1 � n + jt yip 0 .. J; �u Lo c r 1. 00 O 0 J `gym N C x �t fi O CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY �• i BOARD ACTION: AUGUST 15, 2006 Claim Against the County,or Distlict Governed by ) the Board of Supervisors, RoutinglEndorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to ) The copy of this document mailed to California Government Codes. ) you is your notice of the action taken $pyerviu.ojras1. our cm by the Board of 1y l� (Paragraph IV below), JUL 2 7 ZppgenPrsuant to Government Code tion 9.13 and 915.4. Please note all AMOUNT: UNKNOWN COUNTYCOUNSEL Warnings". CLAIMANT: KEITH ALLEi BOWEN MARTINEZ CALIF. ATTORNEY: LOUANNE NASRY WEEKS DATE RECEIVED: JULY 27 , 2006 LAW OFFICES OF NASRY & VITITOL ADDRESS: 5707 CORSAI AVENUE, 2ndBFWBEIVERY TO CLERK ON: JULY 27 , 2006 WESTLAKE VILLAGE, CA 91362 IBY MAIL POSTMARKED: HAND DELIVERED .FROM: Clerk of the Board ofSuper-visors TO: County Counsel Attached is a copy of the above-noted claim. JULY 27, 2006 JOHN CULLEN, er Dated: By: Deputy IL FROM: County Counsel I T0: Clerk of the Board of Su ervisors (�iis 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 clahn (Section 911.3). O Other: Dated: IF' 1'a(v I By: Deputy County Counsel 111. FROM Clerk of the Board TO: County Counsel (1) County Administrator (2) O Claim was returned as untimely with notice to claimant (Section 911.3). WOARD ORDER: By uanimous vote of the Supervisors present: This Claim is rejected in full. O Other: 1 certify that this is 1 true and correct copy of the Board's Order entered in its minutes for this date. J Dated: 11 OHN CULLEN, CLERK, By Deputy Clerk WARNIN (Gov. code section 913) Subject to centaim exceptions,you have only six(6)months from the date this notice was personally served or deposited in the mail to rile a court action on this claim.See Government Code Section 945.6.You may seek the advice of an attoniey of your choice in connection with this matter. If you want to consult sot attorney,you should do so uuntediately. *Tor Additional Wanting See Reverse Side of'I1iis Notice. AFFIDAVIT OF MAILING I declare under penalty oIf per juiy that I air now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited iu the United States Costal Service int Nha tinez, California, postage folly prepaid a certified copy of this 13mi d Order said Notice [o Claimant, addressed to the claimant as showo above. Dated: /W/ IOIIN CULLEN, CLERK 137 Deputy Clerk i S 07i21i2006 _ 14:37 CONTRA co STA CLERK OF THE 4 - _ 918189916200 N0.365 D01 COUNTY BOARD OF SUPERVISORS OF CONTRA COSTA 6, INSTRUCTIONS TO CLAW-ANT A. A claim relating to a cause of action for death or for injury to person or to personal property or growing crops shall be presented not later than six months after the accrual of the cause of action. A claim relating to any other cause of action shall be presented not later than one year after the accrual of the cause of action. (Gov. Code § 911.2.) J i I I B. Claims must be filed with the Clerk of the Board of Supervisors at its office in.Boom 106, County Administration Building 651 Pine Street,Martinez,CA 94553. C, If claim is against a district golerned by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. I E. Fraud. See penalty for fraudulent claims,Penal Code Sec, 72 at the end of this form. RE: Claim By: Reserved.for Clerk's filing stamp RECEIVED ' Against the County of Contra_ a Costa or ) JUL 2 7 2006 District) CLERK BOARD OF SUPERVISORS (Fill in the name) I } CONTRA COSTA CO, The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named district in the sum of$a6A&NavN and in support of this claim represents as follows: I. When did the damage or injury occur? (Give exact data and hour) 2. Where did the damage or rn ury occur? (include city and county) �Ae OR , ZVW;l 3, How di the damage el-or injury occur? (Give full details;use extra aer if required OMWma� was 151LJure,�' o�gMa�osiso�'�2 wkr94zzalo�-- sn1-4eAXe4Ac4i2v,`iihere 6v-b ov4rltaq d1/0°& 4��&6 were fatrefiav 4. What particular act or omission on the part of county or district officers, servants, or employees caused the injury or damage? 77a M,�veAt e f h fj ,C� �r,2 Fr4r, e t�7�Z4 0-07-ZOe7*1e o-n4eAU cres c! 42 c�� ur wAede`bbAr� 5"Ae ,Jt!F /VOma.*/�iN6-- Or er d�lo�e 5 ghat are the names of county or district officers,servants,or employees causing the rU�"`'/ damage or injury? Q�7Ve� e�rf_ GC�KNow� a4l flus f�ixQ mak �� �� I ® R,IGINAL 07i21i200_ 5 14:37 CONTRA COSTA COUNTY CLERK OF THE 4918189916200 --- <<. . ----- N0.365 _. 902 6. What damage or injuries do your claim resulted? (Give full extent of injuries pr damages claimed, Attach two estimates for auto damage.) 0 t4/00 lAq1_/ja rlo./Az Sei"Q 119Qal6�mq A01-' &,&Zt.,C aad�PA4�- o-/AC49,se "VN45.9 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) JCAVI"a�yJ au&".07-per yaedyeap 46dZS Z7•tl rsd�'� � 8. ames an addresses of witnesses,doctors and hosp talc: 0�2s Med4agk 9,r- -CAA NAO ! .MrIv- aoi Aw- ccC,¢eh C 7� t/aZ4,e�,� lew 8 AY 9. List the expenditures you made on account of "s accident or injury. 71te EW PATM TINE AMOUNT a•1•a\\1\\\\\�\\.\�\�\1111\\Ia•1\•�\.\■aaalallalaa\aaala.laa alae allows\aaoaa•mop ass 1.1 } Gov.Code Sec. 910.2 provides"The claim shall be }signed by the claimant or by some person on his }behalf:" SEND NOTICES TO: (Attorney) ) ' Name and address of Attorney ) ak LDllgff�e 1�4s,� W�°P.�s F.Sc�} >=�v U�fi[2S Gf`/l/A,f�t1b .�'ii�>�D�� (Claimant ignature} 5-7-0-7 k '�.�Pf&*_p V/ ) (Addtess) GV ea,W I/lGl�-e O9 36U, Telephone NoIJXY }Telephone No, I •\*Igoe rSees\Iatom\\\.a.aaaaaalaVOW a■alaa\.aaaa as***seats as 118606.•ro a.a a Sees`.a.a.■.t PUBLIC RECORDS NOTICE: Please be advised that this claim form, or+any claim filed with die County under the Tort Claims Act, is subject to public disclosure under the California Public Records Act. (Gov. Code, 95 6500 et seq.) Furthonnore, any attachments,addendums,or supplements attached to the claim form, including medical records,are also subject to public disclosure. ■ass Sea total ass■aa}a•a••■a■aaaaa.a.a 6049asaaaaaaa\\aass•.a.4 as iaaaaa ass NJ aa.am goes sal NOTICE: Section 72 of the Penal Code provides: Every person who,with intent to defraud,presents for allowance or for peyment'to any state board or officer,or ' to any county, city, or district board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account voucher♦, or writing, is punishable either by imprisonment in the County jail for a period of not more than one year, by a fine of not exceeding one thousand dollars ($1,000.00),or by both such imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ($10,000), or by both such imprisonment and fine. J i J SZlSF ha Cel IFpr'yI)p - 2�� TRAFFIC.CQL!ASION REPOW I 'CHP 555 CARS PagL�1-03)ON 061 Page Of 'Z4 SPECIAL CONDITIONS RUl jR E..; CITY JUDICIAL DISTRICT LOCAL REPORT NUMBER 1 Rw 1EL CERRITO BAY SUPERIOR r COUNTYI REPORTING DISTRICT BEAT 06-1789 0CONTRA COSTA EL CERRITO PD 10 COLLISION OCCURRED ON: MO DAY YEAR TIME(2400) NCIC# OFFICER I.D. Z SAN PABLO AVE 1/28/2006 11915 0705 E109 0 MILEPOST INFORMATION: DAY OF WEEK TOW AWAY PHOTOGRAPHS BY: ❑NONE USATURDAYXD YES []NO OFC LEONE AT INTERSECTION WITH: STATE HWY REL X oR 6 FEET SOUTH OF CARLSON BLVD X YES NO PARTY DRIVER'S LICENSE NUMBER STATE CLASS I AIRBAG. SAFETYEQUIP. VEH.YEAR MAKE MODEL/COLOR LICENSE NUMBER STATE 1 N0296041 CA A L G 1993 NISS SEN IRA MAR 3DNK573 CA DRIVER NAME(FIRST,MIDDLE,LAST) X BOB A JAMES - 1 OWNER'S NAME O SAME AS DRIVER PED ADDRESS TRIAN 3425 CARISON BLVD OWNER'S ADDRESSSAME AS DRIVER PARKED CITY/STATE/ZIP . vewcLE EL CERRITO 1 C I 94530 DISPOSITION OF VEHICLE ON ORDERS OF: X OFFICER ❑DRIVER ❑OTHER BICY- SEX HAIR EYES HEIGHT WEIGHT BIRTHDATE RACE EL CERRITO CITY CORP YARD-(S 15-4400 CLIST Mo Dry Vser M BLK BRN 5-11 170 7/27/1954 B PRIOR MECH.DEFECTS NONE APP. )( REFER TO NARRATIVE OTHER HOME PHONE BUSINESS PHONE I VEHICLE IDENTIFICATION NUMBER IN4EB32AXPC744131 (510)527-0438 (5I0)464-7000 VEHICLE TYPE DESCRIBE VEHICLE DAMAGE SHADE IN DAMAGED AREA INSURANCE CARRIER POLICY NUMBER ❑UNK ❑NON MINOR AAA AJ-45-31-6 I 01 MOD DMAJOR ROLL-OVER DIR OF TRAVEL ON STREET OR HIGHWAY SPEED LIMIT S SAN PABLO AVENUE J 35 CA DoT cAl-T TCP/PSC MDIMx PARTY DRIVERS LICENSE NUMBER STATE CLASS NR BAG SAFETY EQUIP. VEH.YEAR MAKE I MODEL I COLOR LICENSE NUMBER STATE 2 N2013743 CA C DRIVER NAME(FIRST,MIDDLE,LAST) ❑ KEITH ALLEN BOWEN OWNER'S NAME ❑SAME AS DRIVER t/ PEDES TRIAN X 400 ADAMS ST QWNERS ADDRESS ❑SAME AS DRIVER PARKED CITY I STATE I ZIP VEHICLEALBANY CA 94706 DISPOSITION OF VEHICLE ON ORDERS OF: ❑OFFICER ❑DRIVER ❑OTHER BICY- . SEX HAIR EVES HEIGHT WEIGHT BIRTHDATE RACE• CLIST Me Day Ym M BLK BRN 6-04 240 3/17/1956 B PRIOR MECHANICAL DEFECTS NONEAPP. REFER TO NARRATIVE OTHER HOME PHONE BUSINESS PHONE VEHICLE IDENTIFICATION NUMBER (510)559-1208 ( ) VEHICLE TYPE DESCRIBE VEHICLE DAMAGE SHADE IN DAMAGED AREA- INSURANCE CARRIER POLICY NUMBER UNK NONEMINOR MOD OR ROLL-OVER DIROFTRAVEL ONSTREET ORHIGHWAV SPEED LIMIT CA DoT W SAN PABLO AVE I 30 C AL-T TCPIPSC MCR.e( PARTY DRIVER'S LICENSE NUMBER $TATE CLASS AIR BAG SAFETY EQUIP. VEH.YEAR IMAKCIMODELICOLOR LICENSE NUMBER STATE 3 DRIVER NAME(FIRST,MIDDLE,LAST)' OWNER'S NAME ❑.SAME AS DRIVER PEDESE STRE A S$ TRIA OWNERS ADDRESS OSAME AS DRIVER PARIS CITY/ TA ZIP vErl III DISPOSITION OF VEHICLE ON OFwaRS OF: OFFICER El DRIVER 7THER BICY- SEX HAIR EVES HEIGHT WEIGHT BIRTHDATE RACE CLI _ Mo D»)' Yser ' PRIOR MECHANCIAL DEFECTS Ll NONE APP. FIREFERTO NARRATIVE OTHER HOME PHONE - BUSINESS PHONE - VEHICLE IDENTIFICATION NUMBER ' I VEHICLE TYPE DESCRIBE VEHICLE DAMAGE SHADE IN DAMAGED AREA INSURANCE CARRIER POLICY NUMBER ❑UNK ❑NONE ❑MINOR, MOD MAJOR ROLL-OVER DIR OF TRAVEL ON STREET OR HIGHWAY + SPEED LIMB DOT CA CAL-T TCP/PSC ML/LO( PREPARERS NAME DISPATCH NOTIFIED REVIEWER'S NAME DATE REVIEWED D.W.HARTUNG E109 I YES CNo NIA u I JSTATE OF CALIFORNIA TRAFFIC !C(dLUSION CODING r CHP 555 CARS Pwje2�Rew 1-03)OPI 061 ` Page 2 of 74 DATE OF COLLISION(MO:DAV YEAR) TIME(2000) NCICI 10 OFFICERIA NUMBER 1/28/2006 0705 E109 06-1789 OWNER - OWNER ADDRESS NOT PROPER ❑YES NO DAMAGE DESCRIPTIONOF DAMAGE SEATING POSITION SAFETY EQUIPMENT INATTENTION CODES OCCUPANTS L-AIR BAG DEPLOYED IVC BICYCLE-HELMET _ A-NONE IN VEHICLE M-AIR BAG NOT DEPLOYED DRIVER PASSENGER A-CELL PHONE HANDHELD B-UNKNOWN N-OTHER V-NO X-NO 8-CELL PHONE HANDSFREE C-LAP BELT USED P-NOT REQUIRED W-YES Y-YES C-ELECTRONIC EQUIPMENT D-RADIO/CD D-LAP BELT NOT USED 1 2 3 1-DRIVER E-SMOKING 2 TO 6-PASSENGERS E-SHOULDER HARNESS USED CHILD RESTRAINT F-EATING 4 S 6 F-SHOULDER HARNESS NOT USED EJECTED FROM VEHICLE 7-STA.WGN REAR Q-IN VEHICLE USEDG-CHILDREN G-LAP/SHOULDER HARNESS USED 0-NOT EJECTED 8-RR.OCC TRK.OR VAN R-IN VEHICLE NOT USEDH-ANIMALS H-IAPISHOULDER HARNESS NOT USED 1-FULLY EJECTED 9-POSITION UNKNOWN S-IN VEHICLE USE UNKNOWN 2_PARTIALLY EJECTED I- PERSONNEL HYGIENE Z 0-OTHER J-PASSIVE RESTRAINT USED T-IN VEHICLE IMPROPER USE J- READING K-PASSIVE RESTRAINTN IT USED U-NONE IN VEHICLE 3-UNKNOWN K-OTHER ITEMS MARKED BELOW FOLLOWED BY AN ASTERISK(•)SHOULD BE EXPLAINED IN THE NARRATIVE. PRIMARY COLLISION FACTORMOVEMENT PRECEDING UST NUMBER(#)OF PARTY AT FAULT TRAFFIC CONTROL DEVICES 12 3 SPECIAL INFORMATION 12 3 COLLISION 1 AVC SECTI N VIOLATED: CITED F- ON X A CONTROLS FUNCTIONING A HAZARDOUS MATERIAL A STOPPED �~iNO B CONTROLS NOT FUNCTIONING- B CELL PHONE HANDHELD IN USE X B PROCEEDING STRAIGHT B OTHER IMPROPER DRIVING' C CONTROLS OBSCURED C CELL PHONE HANDSFREE IN USE C RAN OFF ROAD D NO CONTROLS PRESENT/FACTOR' X X D CELL PHONE NOT IN USE D MAKING RIGHT TURN C OTHER THAN DRIVER* TYPE OF COLLISION E SCHOOL BUS RELATED X - E MAKING LEFT TURN D UNKNOWN' A HEAD-ON F 75 FT MOTORTRUCK COMBO F MAKING UTURN B SIDE SWIPE G 32 FT TRAILER COMBO G BACKING C REAR END { H H SLOWING/STOPPING WEATHER (MARK 1 TO 2 ITEMS) D BROADSIDE 1 11 PASSING OTHER VEHICLE A CLEAR E HIT OBJECT J IJ CHANGING LANES X B CLOUDY F OVERTURNED - K I K PARKING MANEUVER X C RAINING X G VEHICLE/PEDESTRIAN L IL ENTERING TRAFFIC D SNOWING. H OTHER': J M IM OTHER UNSAFE TURNING E FOG/VISIBILITY FT. I I I N I N XING INTO OPPOSING LANE F OTHER.' MOTOR VEHICLE INVOLVED WITH 10 10 PARKED G WIND A NON-COLLISION { P P MERGING LIGHTING X B PEDESTRIAN 0 0 TRAVELING WRONG WAY A DAYLIGHT C OTHER MOTOR VEHICLE OTHER ASSOCIATED FACTORS R OTHER': B DUSK-DAWN D MOTOR VEHICLE ON OTHER ROADWAY L 2 3 (MARK 1 TO 2 ITEMS) X C DARK-STREET LIGHTS E PARKED MOTOR VEHICLE A vc secccttnoH vloureo: c D YES D DARK-NO STREET LIGHTS F TRAIN X ..:' ZI-1 ) ®NO E DARK-STREET LIGHTS NOT G BICYCLE :.: B vc secnon v�ouno: crteo BYES FUNCTIONING' NO H ANIMAL: SOBRIETY-DRUG ROADWAY SURFACE ' VCME oavwureo: Cl o PHYSICAL A DRY ) FIXED OBJECT: B NOB L 2 3 (MARK 7 TO 21TEMS) B WET G X (-� „�� Dtaau A HAD NOT BEEN DRINKING C SNOWY-ICY J OTHER OBJECT: I E VI NT: X B HBD-UNDER INFLUENCE D SLIPPERY(MUDDY,OILY,ETC.) NT IAL ION-: C HBD-NOT UNDER INFLUENCE' ROADWAY CONDITION(S) GST FIC D HBD-IMPAIRMENT UNKNOWN' (MARK i TO 2 ITEMS) PEDESTRIAN' ONS H ENTER RAMP E UNDER DRUG INFLUENCE* A HOLES,DEEP RUT' JA N9 EDESTRIAN PREVIOUS F IMPAIRMENT-PHYSICAL' B LOOSE MATERIAL ON ROADWAY' X B CR �[wN��vr CRO AMILIAR WIT X G IMPAIRMENT NOT KNOWN C OBSTRUCTION ON ROADWAY' ATS tk ECTION � E VEH.EQUIP.: CITED IH NOT APPLICABLE D CONSTRUCTION-REPAIR ZONE C CROSS CROSSWAL - EL Ci ry ) e OS I SLEEPY/FATIGUED E REDUCED ROADWAY WIDTH AT INCE F FLOODED- D CROSSING-NOT IN;CROSSWALK I IL UNINVOLVED VEHICLE G OTHER': E IN ROAD-INCLUDES SHOULDER M OTHER': X H NO UNUSUAL CONDITIONS F NOT IN ROAD i X X N NONE APPARENT G APPROACHING/LEAVING SCHOOL BUS I 1 10 RUNAWAYVEHICLE SKETCH I n MISCELLANEOUS - Z(' d" I (� {, INDICATE NORTH �. { LL CCI�.1'Zc`f 4' ( STATE OF CALIFORNIA I INJURED/WITNE8SES!PASSENGER! Page 3 or CHP 555 CARS PJ'e 3 Red 1-03 OPI 061 DATE OF COLLISION(MO. DAY YEAR) TIME(2400) NCIC# OFFICER I.D. NUMBER 1/28/2006 1915 .07051 E109 06-1789 WITNESS PASSENGER AGE sEx EXTENT OF INJURY(-X`ONE) INJURED WAS('X'ONE) PARTY SEAT AIR SAFETY EJECTED ONLY ONLY NUMBER POS. BAG EQUIP. FATAL SEVERE OTHER VISIBLE COMPLAINT DRIVER PASS. PED. BICYCLIST OTHER IWURY INJURY INJURY OF PAIN ❑# ❑ 49 M ❑ ❑ ❑ ❑ ❑ ❑ ❑ 2 0 1 1 1 0 NAME I D.0.6./ADDRESS TELEPHONE KEITH ALLEN BOWEN (03/17/1956) 400 ADAMS ST ALBANY CA 94706 (510)559-1208 (INJURED ONLY)TRANSPORTED BY: TAKEN TO: AMR DOCTORS HOSPITAL SAN PABLO DESCRIBE INJURIES: SPRAINED LEFT ANKLE,CONTUSIONS ON RIGHT KNEE AND ELBOW. VICTIM OF VIOLENT CRIME NOTIFIED ❑X # 1 ❑ 45 1 F I ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ NAME/D.O.B.I ADDRESS I TELEPHONE ALICE T MEDIA (10/25/1960) 702 JOHNSON ST ALBANY CA 94706 (510)527-2203 (INJURED ONLY) NSPORTED BY: TAKEN TO: DESCRIBE INJURIES: t Ll VICTIM OF VIOLENT CRIME NOTIFIED �# 2 ❑ 59 M ❑ ❑ EJ ❑ 1011:111:11 ❑ ❑ NAME/D.O.B./ADDRESS I TELEPHONE BRACE WONG (10/07/1946) 24 CAULFIELD CT PETALUMA CA 94954 (707)763-7129 {INJURED ONLY)TRANSPORTED BY: CONF/ TAKER Cv CC��✓�� CENT DESCRIBE INJURIES: ENF, AY EMeNT ORAGENCYNCy. JOONNYVICTIM OF VIOLENT CRIME NOTIFIED iqFQ O# 3 ❑ 39 M I ❑ ❑ NAMED.O.S.l ADDRESSERRITp p TELEPHONE GEORGE D CLEVELAND (08/23/1966) 4000 LAMBERT RD EL SOBRANTE CA 94��/CE 10 ED ONLY)TRANSPORTED BY: TAKEN TO: DESCRIBE INJURIES: VICTIM OF VIOLENT CRIME NOTIFIED ❑X # 4 ❑ 163 1 M I ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ NAME/D.O,B.I ADDRESS I - TELEPHONE DAVID DONALD ANDERSON (09/20/1942) 787 TAFT STREET ALBANY CA 94706 (510)527-5076 (INJURED ONLY)TRANSPORTED BY: TAKEN TO: DESCRIBE INJURIES: VICTIM OF VIOLENT CRIME NOTIFIED 0# 5 ❑ 61 F I ❑ I ❑ I ❑ 1 ❑ 1 111111111 ❑ I ❑ NAME/D.O.B./ADDRESS . J TELEPHONE CATHY ANDERSON (07/13/1944) (INJURED ONLY)TN PORTED BY: TAKEN TO: (510)527-5076 DESCRIBE INJURIES: VICTIM OF VIOLENT CRIME NOTIFIED PREPARERS NAME I.D.NUMBER MO. DAY YEAR REVIEWER'S NAME MO. DAY YEAR D.W.HARTUNG E109 1/28/2006 i ESTATE OF CALIFORNIA FACTUAL DIAGRAM CHP 555 Page 4(Rem.8-Fo)PI 042 �. Paosil of DATE OF COLLISION(MO. DAY YEAR) TIME(2100) NGC a OFFICER I.D. NUMBER Cl ALL MEASUREMENTS ARE APPROXgMTE AND NOT TO SCALE UNLESS STATED (SCALE I Jf I S4N A�E INDICATE NORTH i q7 I I li I I ! � CARLSov BcvO• [+w WR CURE) CONFIDENTIAL GG6MWI2my INFLAW ENFORCEMENT AGENCY 3 MATONLY ON TO: AGENCY: BY: ` SATE: I s EL CERRITO POLICE I tt OX 4 +yr s 2 1 ro I EL cck/IF>°o X sAa Pio �f--(� -�'E--- I I• I I � I I I I � I PREPARED BY I.D.NUMBER I MO. DAY YEAR REVIEWER'S NAME MD. OAY YEAR OSP 99 28973 I s EL CERRITO POLICE DEPARTMENT 2006-1789 CA0070500 10900 San Pablo Ave • EI Cerrito, CA 94530 (510)215-4400 - FAX(510)235-6618 DIAGRAM LEGEND V-1 (Nissan) RR 18' 8" east of the west curbline of San Pablo Avenue and 44' 5" south of the prolongation of the south curbline of Carlson Blvd. RF 18' 7" east of the west curbline of San Pablo Avenue and 51' 9" south of the prolongation of the south curbline of Carlson Blvd. C@fnQ CLL2Z) �I'UNFIpENTIAL LAW ENFORCEMENT AGENCY FO DATION U. USENLY ';>ENcy. I - ro Aaron Leone 433 E111 January 29, 2006 STATE OF CALIFORNIA NARRATIVE/SUPPLEMENTAL PAGE OF ZI DATE OF INCIDENT TIME NCIC NUMBER OFFICER I.D. NUMBER :01/28/2006 1915 0705 E109 06-1789 1 FACTS: 2 3 NOTIFICATION: I was dispatched to a call of an injury traffic collision, with an ambulance 4 responding at 1918 hours at San Pablo Ave and Carlson Blvd. I responded from San 5 Pablo Avenue and Moeser Lane and arrived on scene at 1922 hours. All times, speeds 6 and measurements in this investigation are approximate. Officer Leone completed all 7 measurements which were taken by rollmeter, except where otherwise indicated. 8 9 SCENE: At the scene of this collision, San Pablo Ave is a northbound/southbound city 10 street consisting of four lanes. The roadway is straight and level. The surface is composed 11 primarily of asphalt bordered on the east and west by raised cement curbs. There is a 12 raised center median south of the southern crosswalk line. San Pablo Ave is intersected by 13 Carlson Blvd. Carlson Blvd is an eastbound/westbound city street consisting of four lanes. 14 The roadway is straight and level. The surface is composed primarily of asphalt. The 15 intersection is signal controlled with audible signals system present for visually impaired 16 pedestrians; white painted crossw�° s�gi4r�1�e south, east, and west sides of the 17 intersection. There is oveftad-iig ing facet#� on each all four corners of the intersection. 1 NT 18 At the time of the colli'-i 'h rTiead�die fij1196batin,e toe (Osoutheast and northeast 19 corner of the intersection were no tiorling.. ' LY 20 r'\ 21 PARTIES: ` 22 23 PARTY# 1 (James) was located standing on the center median adjacent to Party#2 24 (Bowen) at 1923 hrs. Partys#1 James was identified by a valid California driver's license. 25 James was placed as a party by the following items: 26 - Driver statements 27 - Witness statements 28 - Driver is registered owner PREPARED BY I.D.NUMBER DATE REVIEWER'S NAME DATE D. W. HARTUNG El 091 01/28/2006 STATE OF CALIFORNIA NARRATIVE/SUPPLEMENTAL PAGE!J OF 'X1 DATE OF INCIDENT TIME NCIC NUMBER OFFICER I.D. NUMBER 01/28/2006 1915 0705 E109 06-1789 1 - Driver in possession of keys 2 3 NISS SENTRA Driver# 1's vehicle was located on its wheels as shown on the diagram. 4 Vehicle damage was observed to the driver's side view mirror and a large circular impact 5 crack to the upper driver's side windshield. 6 7 PARTY # 2 (Bowen) was located laying in the number #1 southbound traffic lane of San 8 Pablo Avenue adjacent to the southern most white painted pedestrian crosswalk line at the 9 intersection of San Pablo Ave and Carlson Blvd. Boweri was attended to by EI Cerrito Fire 10 Department and AMR personnel prior to being transported to Doctors Hospital in San 11 Pablo. 12 13 14 PHYSICAL EVIDENCE: 15 Digital photographs of the scene were taken by Officer Leone (Refer to attached 16 supplement). Broken piecesc sidg��i r wereg,located approximately 6 feet south of 17 the southern crosswalk lin ace ear � l celr> �kmedian. 18 19 STATEMENTS: \ ��Fti itis Cy�s'QR� 20 21 PARTY # 1 (James) Stated he had been shop gnate ones rug Store in the EI 22 Cerrito Plaza shopping < cent er. He left the store driw -1�st n in the number 2 exit 23 lane for the western entry and exit to the shopping cen she approached the 24 intersection of San Pablo Ave he observed the traffic signal for traffic lane was solid 25 green. He entered the intersection at a speed of approximatly 2-3 mph and turned left onto 26 southbound San Pablo 4e number 1 traffic lane. As he was crossing the painted 27 crosswalk on the south side of the intersection he collided with P-2 striking him with the left 28 side of his vehicle near the driver's door causing P-2 to fall to the ground. PREPARED BY I.D.NUMBER DATE REVIEWERS NAME DATE D. W. HARTUNG E109� 01/28/2006 STATE OF CALIFORNIA NARMTIVE/SUPPLEMENTAL PAGE 10 OF 2i ,DATE OF INCIDENT TIME NCIC NUMBER OFFICER I.D. NUMBER 01/2812006 1915 0705 E109 06-1789 1 2 When James realized he had struck P-2 he pulled forward stopped and exited his vehicle to 3 check on the welfare of P-2. While entering and conducting his turn at the intersection 4 James said he did not see P 2 at anytime prior to the collision. 5 6 7 PARTY # 2 (Bowen) was contacted on 01-29-2006 at the 1841 hours at 400 Adams St in 8 Albany and interviewed regi rding the events of this collision. P-2 Bowen told me he is 9 temporarily living at the aforementioned address while going through a 10 training/rehabilitation program for visually impaired/blind persons. Bowen said he has no 11 vision out of his right eye and is able to see images, lights and shadows out of his left eye. 12 Bowen said he has been at the facility since approximately September 2005. 13 14 Bowen said on 01-28-2006 he was crossing San Pablo Ave at Carlson Blvd utilizing the 15 southern crosswalk of San Pablo Ave and walking west. Prior to entering the roadway he 16 stopped at the pedestrian signal control buttowipnc�J activated the signal to cross from the AWN �.�^�i11'^; 17 east side of San Pablo Ave to thewest;sift,Affef�activating the button Bowen said he took Fl4V E;NF Hr;�;,nF 1"FOHMAT;0N 18 one side-step to his right,#o__a tign himsel with R6 p66s§waW ,.Bowen said as part of his GiENCY; 19 training/rehabilitation program he"Psas-been-taught-that_tt6egE7�sfnan,�signal box for the 20 crosswalk is aligned with the sosswalk and talcPng aside step places EL CERRI`i ; PpLICE 21 him him in proper position to cross within the crosswalk. Bowen said while there is an audible 22 signal for visually impaired)persons at the intersection, he has been instructed not to utilize 23 this as a queue to cross the roadway. Bowen said he was able to determine he had the 24 right-of-way by noting whin traffic is passing him to the right as he faces west at the 25 crosswalk. This indicates a red light for north and southbound traffic on San Pablo Ave and 26. a green light for east and westbound traffic on Carlson Blvd and for traffic exiting out of the 27 EI Cerrito Plaza shopping center. Bowen said he is also able to see images enough to tell 28 when the left turn pocket lane for northbound San Pablo Ave is stopped which provides him PREPARED BY I.D.NUMBER DATE REVIEWER'S NAME DATE D. W. HARTUNG E109 01/28/2006 STATE OF CALIFORNIA NARRATIVE/SUPPLEMENTAL PAGE►i OF Li DATE OF INCIDENT TIME NCIC NUMBER OFFICER I.D. NUMBER 01/28/2006 1915 0705 E109 06-1789 1 with queuing on the traffic signal sequence. Bowen waited until traffic on northbound San 2 Pablo Ave had stopped and tthen traffic traveling east across San Pablo Ave in to the EI 3 Cerrito Plaza was passing him before proceeding into the crosswalk westbound. Bowen 4 said he was slightly past the middle of the crosswalk when he was struck on his right side 5 from a vehicle he believed was coming from behind and to the right of him. Bowen said the 6 next thing he knew he was laying on the ground and people were checking on his welfare. 7 8 1 asked Bowen if he was utilizing the white cane which was found lying on the ground in 9 proximity to him on the night i f the collision. Bowen said the cane was his and at the time ,10 of the collision he was utilizing the cane. I asked Bowen how often he had crossed the 11 intersection where the collision occurred. Bowen said he crosses the intersection almost 12 daily between 5-10 times as part of his training/rehabilitation. 13 14 WITNESS # 1 (Alice Melia) was contacted standing on the east sidewalk IFO 9895 San 15 Pablo Ave (Peet's Coffee). Mejia related that she driving southbound on San Pablo Ave 16 and had stopped for a red traffic signal in the #2 southbound traffic lane of San Pablo Ave 17 at Carlson Blvd. While awaiting the traffic signal she-obsery %V-1 entering the intersection 18 from the El Cerrito Plaza ShoppingGee�s� �` lin'0 aMAg fraveN ge���stb und`"direction in the #2 19 traffic lane. She observed the v�h�iEla�tlirgjeW!h6 o ,� aSan to Ave and collide 0N4 20 20 with P-2 who was walking adb,J ss ei er/'6n within t Inted crosswalk in a 21 westbound direction. e t p'a'rLfrom thee- Iseotf i d P-2 to be thrown up into the air GEN .T o F 22 and then land back on the Hca ar'� " e��t�ntly the ground. Mejia said it appeared the ,= r 23 driver of V-1 did not see 0-2 who was walking with a white cane at the time of the collision 24 within the painted crosswalks and a few feet past the center median. Mejia also believes 25 V-1 was traveling at a high rate of speed at the time of the collision. 26 27 WITNESS # 2 (Brace Wong) was contacted Inside 9895 San Pablo Ave. Wong related 28 that he was sitting inside Peet's Coffee (9895 San Pablo Ave) at a window table facing in a PREPARED BY I.D.NUMBER DATE REVIEWER'S NAME DATE D. W. HARTUNG E109 01/28/2006 STATE OF CALIFORNIA NARLZATIVE/SUPPLEMENTAL PAGE R OF Z/ DATE OF INCIDENT TIMENCIC NUMBER OFFICER I.D. NUMBER 01/28/2006 1915 0705 E109 06-1789 1 northern direction. He was looking out the window and observed P-2 crossing the 2 intersection within the southern crosswalk with a white cane. As he was watching P-2 he 3 observed V-1 turn left from Iwestbound San Pablo Ave on to Southbound San Pablo Ave 4 striking P-2. The vehicle pulled forward and the driver P-1 exited and went over to where 5 P-2 was laying on the ground. Wong said at the time of the collision he did not notice the 6 traffic signals. 7 8 WITNESS # 3 (George Cleveland) was contacted By Officer Zink. 9 Refer to attached statement. 10 11 WITNESS # 4 (David Anderson) was contacted by Officer Leone. I 12 Refer to attached statement. 13 14 WITNESS # 5 (Cathv Anderson) was contacted Officer Leone. I 15 Refer to attached statement. 16 17 OPINIONS AND CONCLUSIONS: CCH7R, LG cG'MG"��G's`'� 18 CONFIDENTIAL INFORMATION 19 SUMMARY: TO; LAW ENFORCEMENT AGENCY USE ONLY AGNCY: 20 P-1 was driving V-1 westEouncrin-ttre---across-Sarr-P-ablo_Aue maE a left tum on to 21 southbound San Pablo .a :nt rnbw-" -2 who is vlsua y andicapped was EL CERRITO POLICE 22 crossing within the southern crosswalk of the intersection of San Pablo Ave and Carlson 23 Blvd. P-1 failed to see P-2I within the crosswalk and struck him with V-1 causing injury to P- 24 2. 25 26 AREA OF IMPACT: 27 The area of impact is estimated to be 6 feet south of the prolongation of the southern curb 28 line of Carlson Blvd and 26' V west of the western curb line of San Pablo Ave. PREPARED BY I.D.NUMBER DATE REVIEWER'S NAME DATE D. W. HARTUNG E109 01/28/2006 STATE OF CALIFORNIA j NARRATIVE/SUPPLEMENTAL PAGE [A OF 2( DATE OF INCIDENT TIME NCIC NUMBER OFFICER I.D. NUMBER 01/28/2006 1915 0705 E109 06-1789 1 Determination of the A.O.I is based on statements of witness, P-1 and P-2. 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 1, 23 24 25 —� 26 CAUSE: `.- 27 P-1 (James) caused this collision by driving V-1 (Nissan) in violation of Section 23152(a) 28 CVC, Which states in part that it is unlawful for any person who is under the influence of PREPARED BY I.D:NUMBER DATE REVIEWER'S NAME DATE D. W. HARTUNG E109 01/28/2006 STATE OF CALIFORNIA NARRATIVE/SUPPLEMENTAL PAGE14OF 21 DATE OF INCIDENT TIME NCIC NUMBER OFFICER I.D. NUMBER 01/28/2006 1915 0705 E109 06-1789 1 any alcohol beverage or drug to. drive a vehicle. An associated factor to this collision was 2 James failing to yield the right of way to a visually handicapped pedestrian in violation of 3 Section 21963 CVC which states, in part a totally or partially blind who is carrying a 4 predominantly white cane, or using a guide dog, shall have the right-of-way. 5 6 7 RECOMMENDATIONS: 8 9 I recommend a copy of this report be forwarded to the district attorney's office for 10 prosecution of P-1 James fbr violation of Section 23153(a) CVC, driving under the influence 11 of alcohol and/or drugs and being the proximate cause of this collision which resulted in 12 injuries to P-2 Bowen. 13 CC C'°GMG7CG�� INFORMATION FNTIAL GENCY USE ONJY CO,NAvV ENFORCEMENT A - O f�- CFnnLTO POUGF PREPARED BY I.D.NUMBER DATE REVIEWER'S NAME DATE D. W. HARTUNG E109 01/28/2006 J — Z/ EL CERRITO POLICE DEPARTMENT 2006-01789 CA0070500 10900 San Pablo Ave • El Cerrito, CA 94530 (510)215-4400 • FAX(510)235-6618 Supplement: On 1-28-06 I arrived at Doctor's Hospital in San Pablo where I observed BAD Phlebotomist Young draw blood from (V) Bowen. Young turned over the samples to me which I sealed and later placed into the evidence refrigerator at ECPD. I also retrieved Bowen's torn clothing which I booked into evidence at ECPD. �C�5U7GG(�u�4 INFORMP:�ION TIAL -T AGENCY USE ONLY CO AVq eNFORCEMEN - ;'�: f F O PU OCE Purdy El 17 January 29, 2006 EL CERRITO POLICE DEPARTMENT 2006-1789 CA0070500 10900 San Pablo Ave • EI Cerrito, CA 94530 (510) 215-4400 • FAX(510)235-6618 Supplement: On 1/28/06 I was dispatched to the area of San Pablo Avenue and Carlson Blvd for a report of a vehicle accident involving a pedestrian. Upon arrival I conducted traffic control and assisted in securing the scene until the pedestrian was transported. After securing the scene I was approached by a white male who identified himself with his California Driver's license as George Cleveland and he stated he had seen the accident and the following is a summary of his statement. Cleveland said he was in his vehicle in the#1 left turn lane on southbound San Pablo Avenue waiting to turn left into the Plaza. There were approximately 3 vehicles ahead of him when he witnessed the accident. The light for southbound traffic for San Pablo Avenue was red. He stated he saw the red vehicle proceeding southbound in the#1 lane of San Pablo Avenue while the pedestrian was westbound just outside the crosswalk. Cleveland estimated the vehicle speed at 15-20 mph when the front end struck the pedestrian. Cleveland showed me where he believed the pedestrian to be which was approximately 5' west of the center median and approximately 5' south of the crosswalk in the number one lane of southbound San Pablo Avenue. Cleveland thought the peldestrian was pushing a shopping cart and he was wearing dark clothing. Cleveland thought the driver was a male but could not identify the pedestrian or the driver. I concluded the interview. CCHTU�2: LL; I ��CC�N1G.•Gsho�,,� CONFIDENTIAL INFORMATION TO: LAW ENFORCEMENT AGENCY USE ONLY AGENCY: William K. Zink #56 January 29, 2006 EL CERRITO POLICE DEPARTMENT 2006-1789 CA0070500 10900 SanPablo Ave - EI Cerrito, CA 94530 (510)+15- 4400 - FAX(510)235-6618 W-4 (David Anderson) was contacted at the scene. David Anderson gave me the following statement. He was driving his vehicle exiting the El Cerrito Plaza and turning southbound onto San Pablo Avenue directly behind V-1. David Anderson said they had a green light and were proceeding with the tum when he saw P-2 in the crosswalk near the number one southbound lane of San Pablo Avenue. He could not tell if P-2 was walking eastbound or westbound across San Pablo Avenue. V-1 was traveling between five and ten miles per hour when he saw it collide with P-2. The left side of D-1 near the driver's door hit P-2. David Anderson stopped his vehicle to render first aid to P-2. David Anderson never saw D-1 leave the scene and did not see him ingest anything. W-5 (Cathy Anderson)was contacted at the scene. Cathy Anderson gave me the following statement, She was riding in the right front passenger seat of W-4's vehicle. They were traveling directly behind V-1 exiting the El Cerrito Plaza and turning southbound onto San Pablo Avenue. Cathy Anderson saw P-2 walking in the crosswalk westbound across San Pablo Avenue near the, number one southbound lane. Cathy Anderson said V-1 was traveling about ten miles per hour when she saw it collide with P-2. She saw the left side of V-1 near the driver's door collide with P-2. When David Anderson stopped the vehicle to render first aid Cathy Anderson exited the vehicle and saw several people in the street near P-2. Since there were several people she did not know which one was D-1 so she has no idea if he left the scene or not. Cc,MK U) PC cClL7Gu(sG151 CONFIDENTIAL INFORMATION LAV ENFORCEMENT AGENCY USE ONLY O: - -- ;Y: TATE: EL Po l.i Aaron Leone #33 El l l January 29, 2006 AMENDED CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD:ACTION: AUGUST 15 , 2006 Claim Against the County, or District Governed by ) the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action, All Section references are to ) The copy of this document mailed to California Government Codes. ) you is your notice of the action taken on your claim by the Board of Supervisors. (Paragraph IV below), given Pursuant to Government Code AMOUNT: $50 000 . 00 Section 913 and 915.4. Please note all ' "Warnings". CLAIMANT: PATRICK SHERMENTI #2005014272 ATTORNEY: UNKNOWN DATE RECEIVED. JULY 19 , 2006 ADDRESS: MARTINEZ DETENTION FA03[EDE,IVERY TO CLERK ON: JULY 19 , 2006 901 COURT STREET, RECEIVED FROM MARTINEZ , CAI 94553 BY MAIL POSTMARKED: COUNTY—G9z�c FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JULY 19t 2006 JOHN CULLEN, Cl Dated: By: Deputy II. FROM: County Counsel TO: Clerk of the Board of Supervisors pp&.,h arry (w)r�lhis claim homplies substantially with Sections 910 and 910.2. ( ) This Claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). O Claim is not timely filed. Thel Clerk should return claim on ground that it was filed late and send warning of claimant's right ti apply for leave to present a late claim (Section 911.3), (,.Other eC ,,, 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. OARD ORDER: By unani I ous vote of the Supervisors present: (► This Claim is rejected in full. O Other: J� I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. ' Dated: / (,40f4C] CULLEN, CLERK, By. Deputy Clerk WARNIN('y (Gov. code section 913) Subject to certapr,exceptions,you have only six(6) months from the date this notice was personalty 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 Claiimant, addressed to the claimiYnt as shown above. / Dated, Ara, �EOIIN CULLEN, CLERK ByAvADeputy Clerk V OFFICE OF THE COUNTY COUNSELSILVANO B.MARCHESI COUNTY OF CONTRA COSTA fy-_6>✓ L Off, COUNTY COUNSEL Administration Building 651 Pine Street, 911 Floor SHARON L. /ANDERSON Martinez, California 94553-1229 ',•' =. , ;. CHIEF ASSISTANT _i (925) 335-1800 GREGORY C. HARVEY �; +1:',1\����\ =y i.Z' VALERIE J. RANCHE (925) 646-1078 (fax) a _ AssIsTANTs ooSr�� COU14 NOTICE OF UNTIMELINESS AS TO A PORTION OF THE CLAIM TO: Patrick Shermenti, 2005014272 Martinez Detention Facility 901 Court Street Martinez, CA 94553 Please Take Notice as Follows: In regards to the amended claim you submitted on July 19, 2006, regarding your fingernail fungus, the date noted on the claim, June 5, 2006, is timely. However, any portions of your claim prior to December 20, 2005 still fail to comply substantially with the requirements of California Government Code Sections 901 and 911.2, because theylwere not presented within six months after the event or occurrence _. as provided by law. Because the portions of the claims before December 20, 2005 were not presented within the time allowed by law, no action was taken on those portions of your claims. The claims were forwarded to the Board for action only on the timely portions of the claims. As we previously wrote you,+your only recourse for the untimely portions of your claim is to apply without delay to the County of Contra Costa governed by the Board of Supervisors for leave to present late claims as to the claims which are unti hely. See Sections 911.4 to 912.2, inclusive, and Section 946.6 of the Government Code. Under some circumstances, leave to present late claims will be granted. See Section 911.6 of the Government Code. You may seek the advice of an attorney of your choice in connection with this matter. If you desire to consult an attorney, you should do so immediately. SILVANO B. MARCHESI OUNTY COUNSEL Monika L. Cooper Deputy County Counsel Page 1 Patrick Shermenti Re: Claim of Patrick Shermenti Page Two CERTIFICATE OF SERVICE BY MAIL (Code Civ.Proc., §§ 1012, 1013a, 2015.5; Evid. Code, §§ 641, 664) I am a resident of the State of California, over the age of eighteen years, and not a party to the within action. My b N 'ness address is Office of the County Counsel, 651 Pine Street, 9th Floor, Martinez, CA 94553-1229. On 2720 iO(a I served a true copy of this Notice of Untimeliness as to a Portion of the Claim by Wcing the document in a sealed envelope with postage thereon fully prepaid, in the United States mail at Martinez, California addressed to Patrick Shermenti, 2005024272, Martinez Detention Facility, 910 Court Street, Martinez, CA 94553, as set forth above. I lam readily familiar with Office of County Counsel's practice of collection and processing of correspondence for mailing. Under that practice, it would be deposited with the U.S. Postal Service on that same day with postage thereon fully prepaid in the ordinary course of business. I declare under penalty of perjury under t"'z-.: ws of the State of California and the United States of America that the above is true and correct. Executed on 2 7. bA, -o& at Martinez, California. g Kathleen O'Connell cc: Clerk of the Board of Supervisors (original) Risk Management Page 2 P yy pS l� 5,63♦ � ,CONTRA COSTA COUNTY DETENTION FACILITY (s ) INMATE REQUEST FOR INFORMATIO . (/MEDICAL REQUEST From GA;GfC 'f �Pd+'J[Jyl r' Bkg#,1�rt3( D °7�. 7Q �r 0/ / / 06 Housing g Assignment: E..`, Check One: ( ) �Requestj ( Grievance ( ) Appeal ( ) Other fx Req est;, 1 o 4 Au�'dU,S- d ;VA 1, s Q y% 5 / !��l�i C G �A ;a 1,&,r AN j�� ladi t)'AVO A 6,A It's 047 ' 90 AWAIV15ats RR 17 / X /C Rec'd By RoutedTo: lir ANSWER: II ( } APPROVED ( %�3afe reason ofn� JUL 18 2006 OUNTY COUNSEL pqri By: ter Date: i' / / 6( F Pink Kept by Inmate Yellow:Reply to Inmate White To Booking DET 024 FRM1/2/91 t x Claim to: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT A i Claims relating to causes of action for death or for injury to person or to personal property or growing crops and which accrue on or before December 31, 1987, must be presented not later than the 100'' day after the accrual of the cause of action. Claims relating to causes of action for death or.for injury to person or to personal property or,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. (Gov't Code 911.2.) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street,Martinez, CA 94553. C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at the end of this form. RE: Claim By P�iGk sllb�RE�7 Reserved for Clerk's filing stamp P &A iN E Z JUS Against the County of Contra Costa or ct�RkQoq 1 9 2046 OF District) A°O` L/ � Sv� (Fill in name) A/,.40 cOSrq o�ISo�S 12K tAIAn.)4, ) The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named district in the sum of O coo oo,and in support of this claim represents as follows: 1. When did the damage or injury occur? (Give exact date and hour) �i�lE L£�f Nldovv Piv�E . ; �N�e,PNAI I !/of-'El ePN 4� -4=106 �.�Bl�ac,s��rd'l� 9�G.0 ✓ryd'�l�s�L ��ov� . 2. Where�diidd t-he amage or�ury 0 cur? Qpclude pit and county) f15Z V,6 25, o �Y 1694�svEZ G7 3. How did the damage or injury occur?(Give full details; use extra paper if required) �� vsAa6 BXF .�AvL i - 6i A✓,4fL 4. What particular act or omission on the part of county, or district officers, servants, or employees caused the injury or damage? Q P UJAN P tv vl� No� /�,t?E1c�P/ /o/���p /�lE�l cA�ioN Y� -A-V f1folcqL waAGPMe 5. What are the names of county or district officers, servants, or employees causing the damage or injury? AC. W4 AJ 6. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage.) A:��/e'NJA��s � /t j (y GX.�' ��v�Fx A�� J0`4&y ah PJA'4.r 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 hos tta�l . A24 G 9. List the expenditures you made on account of this accident or injury. DATE TINM AMOUNT ****************************************************************************************** ) Gov. Code Sec. 910.2 provides "The claim must be ) signed by the claimant or by some person on his behalf." SEND NOTICES TO: (Attorney Name and Address of Attorney ) a�6 La xo J a (Claimant's Signature) MOO, 4M -06 a& i0&Signature) (Address) Telephone No. )Telephone No. NOTICE Section 72 of the Penal Code provides: Every person who,with iintenAto defraud presents for allowance or the payment to any state board or officer,or to any county,city,or district board or officer,authorized to allow or pay the same if genuine,any false or fraudulent claim,bill,account, voucher,or writing,is punishable either by imprisonment in the county jail for a period of not more than one year,by a fine of not exceeding one thousand(S 1,000),or by both such imprisonment and fine,or by imprisonment in the state prison,by a fine of not exceeding ten thousand dollars($10,000),or by both such imprisonment and fine. y{� ,,CONTRA COSTA CO UN `Y � DETENTION FACILITY ( ) INMATE REQUEST FOR INFORMATION- (/MEDICAL REQUEST From Bkg#,:2 C �� (DOB)_. ` Date;. b /_c_ i 06 Housing Assignment.,P' 'L� Check One: ( ) Request'! Grievance ( ) Appeal ( ) Other Reques011 t A POE o i; ®" 5555 J GLV „ Recd By r.. Routed To: ANSWER:-. ( )APPROVED ( sate rea on 'JUL 1 s Zoos 1 %(J " OUNTYCOUNSEL i i By: /�� Date Pink:Kept by lninate Yellow:Reply to Inmate White:To Booking DET 024 FRM1/21191 1 . Office of the County Counsel Contra Costa County 651 Pine Street, 9th Floor Phone: (925) 335-1800 Martinez, CA 94553 Facsimile: (925) 335-1866 Writer's Direct Dial: (925)335-1885 Date: July 19, 2006 To: Clerk of the Board of Supervisors Cc,r, ?005 Attn: Emy Sharp, Deputy Clerk From: Silvano B. Marchesi, County Counsel By: Monika L. Cooper, Deputy County Counsel (Y) Re: Amended Tort Claims of Patrick Sherminti Please process the attached claims from Patrick Sherminti as amended claims. Thank you for your assistance. Please call with any questions. Attachments CONFIDENTIAL ATTORNEY CLIENT DOCUMENT r a � r i r . r .r �r r i AMENDED CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY ° BOARD,ACTION: AUGUST 15 , 2006 Claim Against the County, or District Governed by ) the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to ) The copy of this document mailed to California Government Codes. ) you is your notice of the action taken on your claim by the Board of Supervisors. (Paragraph IV below), given Pursuant to Government Code AMOUNT: $10,000 ,000. 00 Section 913 and 915.4. Please note all "Warnings". CLAIMANT: PATRICK SHERMENTI' #2005014272 ATTORNEY: UNKNOWN DATE RECEIVED: JULY 19 , 2006 ADDRESS: MARTINEZ DETENTION FAU,DELIVERY TO CLERK ON: JULY 19 , 2006 901 COURT STREET, RECEIVED FROM MARTINEZ, CA 94553 BY MAIL POSTMARKED: GBT�-- UN V�91IINGEI � -G� -�L FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JULY 19 , 2006 JOHN CULLEN, er Dated: By: Deputy II. FROM: County Counsel TO: Clerk of the Board of Su "ervisors �a ifi q�/y (v)''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). 64—Other: —mac'—c cOy�7�1 Dated: 7����� By: Deputy County Counsel III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) O Claim was returned as untimely with notice to claimant (Section 911.3). I\, BOARD ORDER: By unani I ous vote of the Supervisors present: (v This Claim is rejected in fill. O Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Date CULLEN,CULLEN, CLERK, By Deputy Clerk WARN (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 ClaiImant, addressed to the claimant as shown above. Dated4*-04�1-IN CULLEN, CLERK By Deputy Clerk QFFld OF THE COUNTY COUNSELSILVANO B.MARCHESI COUNTY OF CONTRA COSTA COUNTY COUNSEL Administration Building SHARON L. ANDERSON 651 Pine Street, 91'Floor CHIEF ASSISTANT Martinez, California 94553-1229 - :-. a, 925 335-1800 AI ' i� GREGORY C. HARVEY ( ) Q; +3;�11NA�� '""' + VALERIE J. RANCHE (925) 646-1078 (fax) ', ��{�' +0 ASSISTANTS r'9 COUIZ� NOTICE OF UNTIMELINESS AS T01A PORTION OF THE CLAIM TO: Patrick Shermenti, 2005014272 Martinez Detention Facility 901 Court Street Martinez, CA 94553 Please Take Notice as Follows: In regards to the amended claim you submitted on July 19, 2006, regarding your psychiatric medication, the date noted on the claim, June 10, 2006, is timely. However, any portions of your claim prior to December 20, 2005 still fail to comply substantially with the requirements of California Government Code Sections 901 and 91l 1.2, because they were not presented within six months after the event or occurrence as provided by law. Because the portions of the claims before December 20, 2005 were not presented within the time allowed by law, no action was taken on those portions of your claims. The claims were forwarded to the Board for action only on the timely portions of the claims. As we previously wrote you, your only recourse for the untimely portions of your claim is to apply without delay to the County of Contra Costa governed by the Board of Supervisors for leave to present late claims as to the claims which are untimely. See Sections 911.4 to 912.2, inclusive, and Section 946.6 of the Government Code. Under some circumstances, leave to present late claims will be granted. See Section 911.6 of the Government Code. You may seek the advice of an attorney of your choice in connection with this matter. If you desire to consult an attorney, you should do so immediately. SI VANO B. MARCHESI COUNTY COUNSEL 00, Monika L. Cooper Deputy County Counsel Page 1 Patrick Shermenti Re: Claim of Patrick Shermenti Page Two CERTIFICATE OF SERVICE BY MAIL (Code Civ. Proc., §§ 1012, 1013a, 2015.5; Evid. Code, §§ 641, 664) I am a resident of the State of California, ver the age of eighteen years, and not a party to the within action. My 9e s address is Office of the County Counsel, 651 Pine Street, 9th Floor, Martinez, CA 94553-1229. On 21-7 k I served a true copy of this Notice of Untimeliness as to a Portion of the Claim by a/cro he document in a sealed envelopes with postage thereon fully prepaid, in the United States mail at artinez, California addressed to Patrick Shermenti, 2005024272, Martinez Detention Facility, 910 Court Street, Martinez, CA 94553, as set forth above. I am readily familiar with Office of County Counsel's practice of collection and processing of correspondence for mailing. Under that practice, it would be deposited with the U.S. Postal Service on that same day with postage thereon fully prepaid in the ordinary course of business. 1 declare under penalty of perjury under the s of the State of C lifornia and the United States of America that the above is true and correct. Executed on 97 at Martinez, California. Kathleen O'Connell cc: Clerk of the Board of Supervisors(original) Risk Management Page 2 �I t CONTRA COSTA`COUNTY I DETENTION"FACILITY , ( ) INMATE'.REQUEST OR INFORMATI N (4MEDICAL REQUEST From /Rl�. �/a/�' GAor i Bkg#A =\rO/�z_ (DOB) Date:�/ �� /'Housing Assignment: Check One: (PY Req{est (Grievance (Appeal ( ) Other Request; i s� 9L A�Pp iG :� � ��' �' viii► � �? 1441se E� Date Rec'dE �� 06, o cog 23 D ' Routed To: jUL 18 2006 - 7 ANSWER: ( ) APPROVED ( ) DENIED state reason) COU TY COUNSEL MARTINEZ CALIF. By: I Date: / / 7 Pink:Kept by Inmate Yellow:Reply to Inmate White:To Booking DET 024:FRM 7/2/91 Claim 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 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 orlgrowing 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. (Gov't 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 Pirie 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 BylNT;4-� S�ERJ1 ^�< Reserved for Clerk's filing stamp aooS-o/ yoZ'I A ) !a� z O '5n1'loau c.1 LfrV Against the County of Contra Costa or JUL 1 9 2006 CLERK BOARD OF SUPERVISORS ,40t/,� 406,1GOXItem Kil- / ({ District) CONTRA COSTA CO. (Fill in name) Arib 1 ) The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named district in the sum of$P®,oac.,00 a and in support of this claim represents as follows: 1. When did the dams or injury occur? (Give exact date and hou� -!D -,Z aO6 D,q��-vF �ivcl tlEa.T �'f_�,� > �000 lda, A/4�t �L t!i'dE'19E1/ANet' sVQ�rj'�Gp 2. Where did the damage or injury occur? (Include city and county) •� ,GjN�Z hDE�A�/D'v �c�L��� 3. How did the damage or injury occur? (Give full details; use extra paper if required) 04e � L #A01; ?*i®4P D I've'140-C '� N 4. What particular act or omission on the part of county or district officers, servants, or employees caused the injury or damage? &Yc/� QR, O e;, 1-.41AgNG.iN � �a Ap� euah 'iAl 01C Axpetl pf1EP)C q r1 M A.J d'd6 E N Q kl;! 6R PRSf S" f'E'/6�S 5. What are the names of county or district officers, servants, or employees causing the damage or injury? D�9 Ael J Al4aL#1 Po 6. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage.) M ode 46AO,Ae'vA/, ��,6(A7v6ArT AP-Je AMU ekJ >� .Y 05,5'.? k; ANor"Aj RAo%w,g igpviegr Svwo,44, fA..,es, cccr ;PAOceZ&-,v5 +w1rA fikc; 4POUVA9 04&', 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) PA d. gtj10 �u��-.el g� woiPRY. /'9EAorA G /g'}V 14 8. Names and addresses of witnesses, doctors, and hospitals. 14<4L M E£JO K U U.P Oo vg GA,j Rive e w 9. List the expenditures you made on account of this accident or injury. DATE TIME AMOUNT ****************************************************************************************** ) Gov. Code Sec. 910.2 provides "The claim must be ) signed by the claimant or by some person on his behalf." SEND NOTICES TO: (Attorney Name and Address of Attorney ) ,AIR E� ) (Claimant's Signature) VaZAeOO' rq�:t-fy (Address) Telephone No. )Telephone No. ****************************************************************************************** NOTICE Section 72 of the Penal Code provides: Every person who,with intent to defraud presents for allowance or the payment to any state board or officer,or to any county,city,or district board or officer,author 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. CONTRA COSTA DETENTION FACILITIES Incident Report Incident Information: Entry Dt1Tm: 06-10-2006 1000 Entered By: LMORR , MORRISON Updated By: Synopsis: Inmate Shermenti disrupted free time this morning with challenging words, gestures and behavior towards several other inmates. He had to be isolated in a visit room. After both Mental Health and Classification interviewed Shermenti, it was determined that he would be moved to Q Module. Incident: 6-10-2006, 1 was working as the as ligned deputy in F Module. Upon relieving Deputy Mulhearn at 0630 hrs. today, I learned that Shermenti was haviI g trouble with his cell mate. According to Deputy Mulhearn, Shermenti was brought out of his cell and allowed to cool off after tensions grew to a point of concern. Deputy Mulhearn attempted to involve Mental Health but they were unavailable until this morning. Approximately 0800 hrs. this date, I was allow ing free time on the B Side of F Module. Shermenti stormed up to the window and told me that I had better move his cell mate out of his room or there would be trouble. He was very animated and irate. I told him that Deputy Mulhearn and 1 had discussed steps to take, and that he simply needed to stay away from any controversy until then. He apologized and left. I observed him go from cell-to-cell, and person-to-person, drawing them into a conversation about his dissatisfaction. It appeared that the people he was talking to were overwhelmed by his hostility. Shermenti then walked out into the exercise area and he began yelling at a cluster of about eight inmates. I ran to the area and told him to go back inside and stay there. I began to speak with the group outside when Shermenti came back outside. He began waiving his arms in a challenging manner and and saying things, i.e. "fuck youl guys," and, " I'll fuck you up punk!" I had to push Shermenti away as he was walking towards the group. He was compliant with me. I took him to visit room 4 and had him wait there for an interview with Mental Health. After her interview, Jerri with Mental Health felt that Shermenti was a threat to many of the inmates based on his perception that they were'against him.' She felt he was particularly inclined to violence at the present time. I had Deputy Jacobson (Classification Unit) interview Shermenti, as well. He again expressed hostility to many inmates in his unit. While waiting in the interview room I observed Shermenti interacting with a number of the inmates through the windows. He was using hand gestures, i.e. the middle finger, and saying provocative things to them. (I am certain he was getting similar treatment from at least some of them.) I advised Sergeant Yates that it seemed prudent to house Shermenti in n Q Module at present, while allowing Classification to determine the best ultimate assignment. He agreed, and Deputy Black took Shermenti to Q Module. Disposition: Shermenti has mental health issues. Discipline can be weighed with that in mind--his ultimate assignment is the larger issue at present. Deputy Lance Morrison 06/10/2006 1129 hrs. cc: Mental Health Classification Facility: 1 Page 2 of 3 Printed: 06-10-2006 1300 5271 MAIN Printed By:53953,EVANS CONTRA 'C05TA COUNTY DETENTION,FACILITY ( ") INMATE REQUUEES/T FOR INFORMATI N, : (MEDICAL REQUEST R ce , Bkg#r,�.daSorynZ (DOB) Date: / _/ Housing Assignment: '71 Check One: }(6�Request Grievance ((Appeal ( )Other ( Request:. I �' � �' Soca -' � .+9't� : r✓ sF► uks k ' f " a I s rPp LAN �"f��f Date Rec'U, (p i �� 0(o n g II RoutedjUL 2006— D ANSWER: ( ) APPROVED ( ).DENIED-state reason) COUNTY COUNSEL MARTINEZ CALIF. ff � s (" Ct{ .ter ;( ,j B : Y � Date: Pink:Kept by Inmate Yellow.Reply to Inmate White:To Booking DET 024:FRM 1/2/91 i ' Office of the County Counsel Contra Costa County 651 Pine Street, 9th Floor Phone: (925)335-1800 Martinez, CA 94553 Facsimile: (925)335-1866 Writer's Direct Dial: (925) 335-1885 Date: July 19, 2006 J(/ � 1 To: Clerk of the Board of Supervisors Gr.F ,,��9 2006 Attn: Emy Sharp, Deputy Clerk GG°r �OF", GgTa GO✓gGHs From: Silvano B. Marchesi, County Counsel By: Monika L. Cooper, Deputy County Counsel (1() C&9puL— Re: Amended Tort Claims of Patrick Sherminti Please process the attached claims from Patrick Sherminti as amended claims. Thank you for your assistance. Please call with any questions. Attachments CONFIDENTIAL ATTORNEY CLIENT DOCUMENT � o � � b 0 Z14 c, o � VN AMENDED CLAIM C BOARD OF SUPERVISORS OF CONTRA COSTA:COUNTY BOARD ACTION: AUGUST 15 , 2006 Claim Against the County, or District Governed,bby the Board of Supervisors, Routi �ity � NOTICE TO CLAIMANT and Board Action. All Section r ce are to The copy of this document mailed to California Government Codes. 1D� L 2 6 2006) you is your notice of the action taken COUNTY COUNSEL on your claim by the Board of MARTINEZ CALIF. Supervisors. (Paragraph IV below), DAMAGES WITHIN THE JURISDICTIOjiven Pursuant to Government Code AMOUNT: OF THE 'SUPERIOR COURT ection 913 and 915.4. Please note all "Warnings". CLAIMANT: JUAN STEWART ATTORNEY: ANDREW C. SCHWARTZ DATE RECEIVED: JULY 26 , 2006 CASPER, MEADOWS , SCHWARTZ JULY 26 2006 ADDRESS: & COOK BY DELIVERY TO CLERK ON: 2121 NO. CALIFORNIA BLVD. , #1020 RECEIVED FROM COUNTY WALNUT CREEK, CA 94596By MAIL POSTMARKED: COUNSEL FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN CULLEN, er Dated: JULY 26 , 2006 By: Deputy IL FROM: County Counsel I 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 cannl t 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: !1 r '�� By: ' Deputy County Counsel III. FROM: Clerk of the Board I TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. ARD ORDER: By unanim us 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. Xl CULLEN, CLERK, By Deputy Clerk WARNIN (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 perjuiry. 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 i Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated. 14 Q< U CULLEN, CLERK By Deputy Clerk I I INS--DCTIONS TO CLAIMANT I A.. A ciaim reianag to a cause of action for death or for injury to person or to personal property or r growing crops shall be presented not later than six months after the accrual of the cause of action. A claim relating to any other cause of action shall be presented not later than one year after the accrual of the cause of action. (Gov, Code § 911.2.) I i 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. i C. If claim is against a district governed by the Baard of Supervisor, rather than the County, the name of the District.should be filled 'in. D. If the claim is against more than o I public entity, separare.claims must be filed against each public entity, E. Fraud. See penalty for fraudurlent claims,Penal Code Sec. 72 at the end of this form.' ■aBtsa'en 99+9o9a�baaa•seava0a090 a.0.9.a.0949000 a s has Ow. one.0006 a 9 a a ma-e 9.900'.009 909 RE:. Claim.By: Reserved.for Clerk's filing JUAN STMART ) c�FAcoOgAO tS?00 .S Against the County of Contra Costa u f District) (Fill in the name) 7 Cp"`ipF7� l The undersigned claimant hereby makes Claim.against the County of Contra Costa or the above-named district in the sum of S * and in support of this claim represents as.follows: *Damages within the 3ur'—'� ctionlof the Superior Court. 1. When did the damage or injury occur? (Give enact date and hour) 12/21/2005 at approximately 6:00 p.m_ 2. Where did.the damage or injury o I ur? (Include city and country) 3936 Angelo Avenue, Oakland, Alameda County, California 3, How did the damage.or injury occur? (Give full details; use extra paper if required) See attached statement for details of the incident and the.acts which caused injuries to the claimant. ) 4. What particular act or omission In the part-of county ordistrict officers, servants, or empioyees caused the injury or damage? See attached statement for details of the incident and teh acts which caused injuries to .the claimant. 5 What are the names of county or district officers, servants, or employees causing the damage or iniUry 7 Contra Costa County Sheriff's employees Lori. Bailey (#52142), Matt Ham`s (#563 9), Sgt. Chris Simmons, Nicole Bolden 060202), and Detective Sutro (#60707), and perhaps other sheriff's deputies who may be involved as well who were on the scene but whose names have not yet been ascertained. F6. What damage or injuries do your .claim resulted? (Give full extent of injuries or damages I claimed. Amich two es=' ams Ior auto damage.) Psychological and emotional trauma as well as an aggravation of a pre ex isting imee injury. it 7: How was the amountci==d ab II e computed? (Include the estimated amount of any prospective injury or damage.) Based on the life-threatening nature of the incident and the apparent threat to the claimant, and the degree of future medical treatment which will be required. S. Names and addresses of wittiesses, doctors, and hospitals: Jeffrey A. Mann, M.D. , 80 Grand Ave., Fifth floor, Oakland, CA 94612-3743 I I .. 9. Lisrthe expenditures you made on account of this accident or injury DATE- TIME AMOUNT i Unknown at present. use am Mali a Uneaaea Daee'.•ria as easy D.en n4.De0 aDoaomw•■7e►b eaeeaoaG.eaaa canoe a one e o aa-...Darnrnl ) Gov, Code Sec. 910.2 provides "The claim.shall be ) signed by the.claimanror by some person on his behalf." SEND NOTICES TO: (Attornevl ) Name and address.of Attamay ) er ANDREW C. SCHWARTZ ) CASPER, MEADOWS, SCHWARTZ & "COOK) (Claimant's Signature) 2121 No. California Blvd. , 11020) Walnut Creek, CA 94596 2121 No. California Blvd. , Ste. 1020 i (Address) } Walnut Creek, CA 94596 I Telephone No. 927-947-1147 )'Telephone No. (925) 947-1147 I woman seam On l6rneae..aa..aea.Ce9news Comment one Vox oaem a-n.eweem eso.nem►.meDsa waene as 0064'91 - FLTBL,IC RECORDS NOTICE: Fiease.be advised thai this claim form, or any claim flied with the County under the Tort Claims Aar, is subject to public.disclosure under the California Public Records ACL,(Gov. Code, §5 6500 et seg.).Farthermore, any attachments, addendums, or supplements attached to the claim form, including medical records are alsosubjectto public disclosure. I II no omean-mea Dane Devens stern aasao aa-eeae.m-■e.sWs a.ee•sa:ea saaae•-e.e outon.maaneo.ne Mann a an above, ) I NOTICE: Section 72 of the Penal Code.provides: Every person who, with intent m 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 sameif genuine, any false or fraudulent claim, bill, account voucher,.or looting, is punishable either by imprisonment in the County jail for a period of not more than one year; by a fine of not exceeding one thousand dollars ($1,000.00), or by both such imprisonment and fine, or by imprisonment.in the state prison, by a fine of not exceeding ten thousand dollars (S l 0,000), or by bath such imprisonment and fine. ATTACHMENT TO CLAwl FORM RESPONSES TO QUESTIONS 13 AND 4 On December 21 , 2005, plaintiff was at his home located at 3936 Angelo Avenue in Oakland at which time the previously identified members of the Contra Costa County Sheriff's Department barged into his home with a search warrant for a different address. The officers burst into plaintiffs home with their weapons drawn and forced him down to the ground, holding a shotgun to his face. Plaintiff used to be a member of law enforcement and had identified himself in such a manner to the Sheriff's Department employees. He had recently undergone surgery to his leg, and so ad lised the officers, but was forced to the ground anyway exacerbating his pre-existing knee injury. Plaintiff has never been arrested and has no prior record and was not wanted for a crime. Plaintiff was severely traumatized by this occurrence. APPLICATION TO FILE LATE CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY CALIFORNIA BOARD ACTION Application to File Late Claim AUGUST 15, 2006 pp ) NOTICE TO APPLICANT 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. I Claimant: .PATRICK K. SHERMENTI VEY � • #2005014272 r Attorney: UNKNOWN JUL 17 2006 ' MARTINEZ DETENTION FACILITY Address: 901 COURT STREET, COUNTY COUNSEL MARTINEZ, CA 94553 MARTINEZ CALIF. Amount: $503000.00 By delivery to Clerk on: JULY 14, 2006 RECEIVED FROM COUNTY COUNSEL Date Received: JULY 14, 2006 By mail, postmarked on:! I. FROM: Clerk of the Board of Supervisors TO: . County Counsel Attached is a copy of the above noted Application to File Late Claim. DATED: JULY 14, 2006 JOHN CUILEN Clerk,By: DEPUTY II. FROM: County Counsel TO: Clerk o theiBoard of 9upervisors ( ) The Board should grant this Application to File Late Claim (Section 911.6)i The Board should deny this Application to File Late Claim (Section 911.6). DATED: 7^1f1.-to(e SILVANO B.MARCHESI, County Counsel,By: mt �� DEPUTY 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 a true.and correct copy of the Board's Order entered in its minutes for this date. D tOHN CULMEN,Clerk, By: DEPUTY WARNING (Gov. Code §911.8) 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 apQjcation for leave to present a late claim was denied. 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. TV- Clerk of the Board I TO: (1) County Counsel (2) County Administrator i 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 been filed and endorsed on the Board's copy of this Claim in accordance with Section 29703. DATED6t.�/(. ,e"6 JOHN CULLEN', Clerk,By: DEPUTY V. FROM: (1) County Counsel (2) County Administrator TV Clerk bf the Board of Supervisors Received copies of this Application and iBoard Order. DATED: County Counsel,By: County Administrator, By: APPLICATION TO FILE LATE CLAIM M Rig 12 IIs�wzmD .Claim fo: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY JUL 1 3 2006 INSTRUCTIONS TO CLAIMANT "- COUNTY COUNSEL A ' Claims relating to causes of action for death or for injury to person or to personal prope Td Mg crops and which accrue on or before December 31, 1987, must be presented not later than the 1000 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. (Gov't 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 Pirie 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/h!{�/G �17�/Q EReserved for Clerk's filing stamp oZ©e 6—elPVA 7�. f'91 Gov ) z . c-,4 i Pz-�O`r-3 RECEIVED Against the County of Contra Costa or ) JUL 1 4 2006 u )<C, Lf6w District) BOARD (Fill in name) ) CLEHJ(CON?RAOCOSTA GO.ISOHS d R. )NON�v ) The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named district in the sum of$ d ooD.c»and in support of this claim represents as follows: 1. When did the damage or injury occur? (Give exact date and hour) ol�Eti° fJ DEPio� 2. Where did the damage or injury occur? (Include city and county) 0414fiw Z�Z a? N Pi4GdLr?� • �i`9R�f/�LtZ G,/Q y7'GfJ � Cosvl4A G� Gov�6r 3. How did the damage or injury occur? (Give full details; use extra paper if required) � wRs3 N4' 6;,VdW -�� �o®�� f�'/�t?l� 9gN I'o� eJN� ✓S AAs ogr Vaercve Armee.® r R i 4, What particular act or omission on the part.of county,,or district officers, servants, or employees caused the injuryor damage?fJ�ri�' R6 rrtri ',To P�P�3C�°j�E co�',� c 1�i �AicA e/J 60 VER 410 zr 5. What are the names of county or distnct officers, servants, or employees causing the damage or injury? DR YvoN 1; 6. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage.) GF iu99eX 4NO AAAA-� fjVe5et1VA�Lg 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.)�a v2s®.vm iJvS6R 8. Names and addresses of witnesses, doctors, and hospitals. 09 W IDN fi I94411116ZL 011[ cR 14 9. List the expenditures you made on a count of this accident or injury. DATE TIME AMOUNT ****************************************************************************************** Gov. Code Sec. 910.2 provides "The claim must be signed by the claimant or by some person on his behalf." SEND NOTICES TO: (Attorney Name and Address of Attorney ) (Ciaimant'.s Signature) a.ao%S-'40/ a2 7,2 to e/ j �el�,v� (Address) /LII iA/,CZ ..�/� ��l►s'���' Telephone No. )Telephone No. NOTICE Section 72 of the Penal Code provides: Every person who,with intent to defraud,presents for allowance or the payment to any state board or officer,or to any county,city,or district board or officer,authoriwd to allow or pay the same if genuine,any false or fraudulent claim,bill,account, voucher,or writing,is punishable either by imprisonment in the county jail for a period of not more than one year,by a fine of not exceeding one thousand(S 1,000),or by both such imprisonment and fine,or by imprisonment in the state prison,by a fine of not exceeding ten thousand dollars($10,000),or by both such imprisonment and fine. N lip pAr/f0,6Z DeTedFvN jiQcK17Y PRgii 4Afs c4AO&W Agi cc lip jw�c ladkO V, 4Ef1UE /Or�i°{Sn+�A 4LAI jW/ A_Jd2T� G�[1NC� ©�GOR /q GOJ/� /NjPf(lIPNi 7e .iiA qi/e 44 wi-rko c ns'4i s o9s �0 t A;wcr., „ ;; ��6 1 At /1' 1� Or goo 'iNo .0 v IGAI'l-1 4=,4l Ori rote. ivi- Ark MAO L4 f d`P lemri0102 �� "saosrEta I Oil lii� r rr t� ia 0 o q4 Z tj � r r f4 `` o 1p r x _ a a .,�,.= Op CSS a APPLICATiION TO FILE LATE CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY CALIFORNIA /® , BOARD ACTION AUGUST 15, 2006 Application to File Late Claim ) NOTICE TO APPLICANT 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 ������o floe "WARNING" below. i Claimant: PATRICK K. SHERMENTI , #2005014272 U� 17 2006 Attorney: UNKNOWN COUNTYCOUNSEL MARTINEZ DETENTION FACILITY MARTINEZ CALIF. Address: 901 COURT STREET, MARTINEZ, CA 94553 Amount: $10,0001000.00 By delivery to Clerk on: i JULY 149 2006 RECEIVED FROM COUNTY COUNSEL Date Received: JULY 14, 2006 By mail,postmarked on: I. FROM: Clerk of the Board of Supe visors TO: County Co'nsel Attached is a copy of the above noted Application to File Late Claim. DATED: JULY 149 2006 JOS CtiLLEN Clerk,By: DEPUTY Il. FROM: County Counsel TO: Clerklof theiBoard f Supervisors ( ) The Board should grant this Application to File Late Claim (Section 911.6) i (,K The Board should deny this Application to File Late Claim (Section 911.6). DATED: 7— 0-04' SILVANO B. MARCHESI, County Counsel,By: M Ceti DEPUTY 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). 1 certify that this a true and correct(copy of the Board's Order entered in its minutes for this date. DATE. Ir, a, 4 4OHN CULLEN, Clerk, By: DEPUTY i WARNING (Gov. Code §911.8) 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 flied with the court within six(6) months from the date your apRjjcation for leave to present a late claim was denied. 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. IV. FROM: Clerk of the Board TO: (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 been filed and endorsed on the Board's copy of this Claim in accordance with Section 29703. DATED: 9===61(e_oOa-e6 JOHN CULLEN', Clerk,By: Lam- DEPUTY V. FROW. (1) County Counsel (2) County Administrator TO: Clerk of the B and of Supervisors Received copies of this Application al d Board Order. DATED: County Counsel,By: County dministrator, By: APPLICATION TO FILE LATE CLAIM Claim to: BOARD OF SUPERVISORS OF CONTRA COSTA COUNrf INSTRUCTIONS TO CLAIMANT JUL 13 2006 COUNTY COUNSEL A. ' Claims relating to causes of action for death or for injury to person or to personal propeayiwWomang crops and which accrue on or before December 31, 1987, must be presented not later than the 10&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 oil 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. (Gov't 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 Pirie 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 Arx)CReserved for Clerk's filing stamp 9a�GbvRl ) RECEIVED /'9Ak�TwEz Q 9 f2 ) Against the County of Contra Costa or ) JUL 1 4 2006 f/UE2 //G/e x rlol�, G i�G I ` District) CLERK BOARD O SUPERVISORS (Fill in name) /q ND ) CONTRA COSTA CO. The undersigned claimant herees claim against the County of Contra Costa or the above-named district in the sum of$Jo 000 God and in support of this claim represents as follows: 1. When did the damage or iinjjury/occur? (Give exact date and hour)) �%E,P /4 9��/`OD06 I�M l��w�/V AC>��t,�< e9� //�"V �G•:.+"GCW� 2. Where did the damage or injury occ r? (Include city and county) 9d� GOt' S -Ar- a A 3. How did the damage or injury occur? (Give full details; use extra paper ifrequired) P9 AWL ipm �F�S�A � �P&sGIP1�9� M� fll- moor-t4 D/v vii tqyex D�✓�� oeN �,>�JN A��E 4S'fi�,olP,r p�,t°rov? :wcAoecE5gT�1V AMAX_ 4. What,particular act or omission on the part of county or district officers, servants, or employees caused the injury or damage?�t�r vs`N� P/ff —41186 /Yg /Y ~40 2� rf/'� 6 A" 5. What are the names y or t o countdisrict officers, servants, or employees causing the damage or injury? 0,R. 6. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage.) R�� 8�N A/ ,,4Feit V® Q � jedIj � 5,,y 6 S"cP;m 1,04is /'/aa/Ac AAA,Gs/� EC 7' _,, 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) Al p 5C,41:En ' A.13 8. Names and addresses of witnesses, doctors, and hospitals. ,OK. "J 9. List the expenditures you made on account of this accident or injury. DATE TDAE AMOUNT ****************************************************************************************** Gov. Code Sec. 910.2 provides "The claim must be signed by the claimant or by some person on his behalf." SEND NOTICES TO: (Attorney Name and Address of Attorney ) (Claimant's Signature) r(Address) I Telephone No. ) Telephone No. NOTICE Section 72 of the Penal Code provides: Every person who,with intent to defraud,presents for allowance or the payment to any state board or officer,or to any county,city,or district board or officer,authorued 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. L'Zi9/M er(J1rxic �omE /�Plo ' i l�oR I-6 AVE 6A iNs�" L 1c F�oA1 AVE 4R oaLjG«s KEN d-N C. �g,A_q) • -6441 Tf�� og/3 �u_P�3:V:Fek's 61� �o,dTi2iq�' Ceup�� av 'A 1 s � �BN • Pik S A N • `s oN ,� ��� ®edr2w(t, IfAj 02 k 'JPdLQAI�/) 1oN oA-tlAlgAWIc 04-140-J-I/ A D 0o ae� got ��.eT's aAR-'1N�,CA 47 VCXV ��Ct�',�LiMR. � •t .� i��>�As�t7�PFSN�r`�/.�Q 'csl��,���-�'k--- 5 ,;1 01) r x f' C� Q 000)4% r , APPLICATION TO FILE LATE CLAIM BOARD OF SUPERVISORS IOF CONTRA COSTA COUNTY CALIFORNIA BOARD ACTION AUGUST 15, 2006 Application to File Late Claim ) NOTICE TO APPLICANT 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. D Claimant: .FRANCISCO DOMINGUEZ (gig CDC # F-22191 C8-105U Attorney: UNKNOWN JUL 17 2006 € KERN VALLEY STATE PRISON COUNTY COUNSEL Address: P.O. BOX 5103 MARTINEZ CALIF DELANO, CA 93216-5103 JULY 17 , 2.006 Amount: UNKNOWN , $y delivery to Clerk on: I Date Received: By mail, postmarked on:' JULY 13 , 2006 I. FROM: Clerk of the Boardof Supervisors TO: . County Counsel .Attached is a copy of the above noted Application to File Late Claim. DATED: JULY 17 , 2006 JOHN Ci�LLEN Clerk,By: DEPUTY II. FROM: County Counsel TO: Cl rk of theiBoar of Supervisors ( ) The Board should grant this Application to File Late Claim (Section 911.6): i ( 4, The Board should deny this Application to File Late Claim (Section 911.6). DATED: � r'�' SILVANO B.MARCHESI, County Counsel,By: /� DEPUTY 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 a true and correct copy of the Board's Order entered in Its minutes for this date. DATE: -SAd®OHN CULLEN, Clerk,By: DEPUTY WARNING (Gov. Code §911.8) 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 ap0cation for leave to present a late claim was denied. 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. IV. FROM: Clerk of the Board TO: (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 been filed and endorsed on the Board's copy of this Claim in accordance with Section 29703. DATE JOHN CULLEN', 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 C lunsel, By: County Administrator,By: APPLICATION TO FILE LATE CLAIM Claim of Francisco Dominguez APPLICATION FOR LEAVE against ��� 1 '7 2006 TO PRESENT LATE CLAIM Contra Costa County rsupERvIsoRs Govt . Code 5911 .4 CLEp.K BOARD 0 CO:Y CRA COSTA CO. To the Board of Supervisors (or other governing body) of Contra Costa County 1. Francisco Dominguez (claimant) hereby applies to the County of Contra Costa, pursuant to Section 911.4 of the California Government Code. 2. The cause of action of claimant as set forth in his proposed claim attached to this application, accured on January 1, 2004 through March 24, 2006, a period within three years from the filing of this application. 3. Claimmant's reason for the delay in presenting his claim against the County of Contra Costa is as follows: a. claimant feared for his life since the Contra Costa County Sheriff murder four inmates in 2005, and an attemp was made against claimant, claimant was unabel to file any claims because the fear. b. claimant did try to file in 2004 but his legal paperwork was lost by the county sherrif. C. claimant has been unable to do any type of anything since March 24, 2006, because he has been moving from one prison to another, now that he has finaly arrived at his final place of incarceration his rights have been restored. 4. All notices and communications concerning this claim should be sent to Francisco Dominguez ) CDC # F-22191 C8-10i5U Kern Valley State Prison PO Box 5103 Delano , CA. 93216-5103 WHEREFORE, claimant asks that you graft this application, deem the attached claim to have been presented on your receipt of this application, and act on the claim as required by Government Code section 911.6 DATED: July 10, 2006 Francisco Dominguez d o N C-1 C A tn N d jl>W o IIA� Wv� r cn r ® co s gig N l� J <c r ¢, D LLI 4r ° � r 4 crVAl2 •� lia o �+ TA �- 1` , j} W APPLICATION TO FILE LATE CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY. CALIFORNIA BOARD ACTION AUGUST 15 , 2006 Application to File Late Claim ) NOTICE TO APPLICANT 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. i Claimant: LOREEN H. JACE and MATTHEW JACE R!UL DAttorney: BRIAN P. EVANS 2 1 2006 LAW OFFICES OF BRIAN Pi. EVANS Address: 200 PRINGLE AVENUE, SUITE 350 COUNTY COUNSEL WALNUT CREEK, CA 945961 MARTINEZ CALIF. Amount: $5 ,000,000 -00 By delivery to Clerk on: JULY 219 2006 I Date Received: JULY 21 , 2006 By mail,postmarked on:: JULY 20 , 2006 L FROM: Clerk of the Board of Supervisors TO: County Coonsel Attached is a copy of the above noted A(plication to File Late Claim. DATED: JULY 21 , 200jjHNCULLEN Clerk, By: DEPUTY T17 County Counsel TO: C erk of theiBoa d of Supervisors ( ) The Board should grant this Application to File Late Claim (Section 911.6)( l/J The Board should deny this Application to File Late Claim (Section 911.6). DATED: -7"25--O(vo SILVANO B.MARCHESI, County Counsel,By: DEPUTY III. BOARD ORDER By unanimous vote of Superlsors present (Check one only) f ( ) This Application is granted (Section 911.6). ( � This Application to File Late Claim is denied (Section 911.6). I certify that this a true and correct copy of the Board's Order entered in its minutes for this date. DATE: oF3N CULLEN,Clerk,By: DEPUTY I 4 WARNING (Gov. Code §911.8) 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 anpeation for leave to present a late claim was denied. 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. IV. FROM: Clerk of the Board TO: (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 been filed and endorsed on the Board's copy of this Claim in accordance with Section 29703. DATED: acd8� &dJ6 JOHN, CULLEN', Clerk,By: DEPUTY V. ROM: (1) County Counsel (2) County Administrator TO: Clerk of the B rd of Supervisors Received copies of this Application and Board Order. DATED: County Counsel,By: County Administrator,By: APPLICATION TO FILE LATE CLAIM RIAN P EVAN.S, ES \. w L A .WOy F F F r TORT CLAIM AGAINST GOVERNMENT AGENCY ��osrpF ;.CONTRA COSTA COUNTY REGIONAL MEDICAL CENTER R�O9`�So9s - 'Contra'CostaCountyyRegional Medical Center' -c/o Contra Costa County;B,oard.of Supervisors' v Marhriez California 94553 r s - , Claimants ., Loreen H:'Jace;and Matthew Jaee c/o Brian,P.'Evans Law Officers of Brian P Evans x 200 Pringle Ave Suite;350 Walnut Creek,'CX 94596` { h Date of Occurrence December 2, 2005 t 'Locat>on Contra C_osfa County Regional Medical Center Nature of Injury ' :Death of`cla mant Loreen-H Jace's spouse and claimant'Matthew`Jace's father, David<G'raham.Jace Circumstances On or about November 29, 2005_`cla>mant.s spouse, David Graham Jace ;was transported"'Via amliulance_to the Contra Costa County Regional 1Vledical Center's.psychiatrac waid, being transported from the John r x :George Psychiatric Pavilion facility an Alameda.County,where decedent. had been on`a suicide watch-and_under`gomg mt`ensive psye atric treatment Defendant,,.Contra Costa County Regional eMedical.Center neglected, failed"and/or refused.fo treat or admit or monitor,satd.decedent ,. but ratherreleased h>m shortly after his arnval and/or*adm> s>on:• By _ v reason of7fsdid prerhik, decedeni committed su>c_ide on-December2,s2005 7-1 Damages Loss of the financial support and.loss of the care, comfort, companionship, aoue,and affection of decedentin,the sum of-$5;000,000:00 ~ 'Please send official notices to the unders>gned ; Dated, July ,Z;e ;2006 At`orney for Claimants, Loreen H. Jace and Matthew Jace e ♦ 1' .."Two Walnut Creek Center c 266 pringle Avenue Suite 350 Walnut Creek CA 94596 1 Telephone925.937.4224 Fax 925 937:4273 BRIAN P: `EUANS, ESQ. c F F ,I: C 'E z , 4, .; � �F9 • X2,1 s , HTgq�FSvA Certifed Mad`Return Receipt Reduested cbsq F is +Contra.'Costa'County Board of Supervisors T�9v o9s .`651 Pirie Street,^V.Floor, Martinez, CA'. 94553 RE 1h The Mattee of the C1kun of Loreen H Jace and son, Matthew Jace;Agd*' t Contra Costa County°RegionaFMedical Center. T =Honorable Members.'of The.Board `Application is liereby`made forpermission to present the attached claim after expiration 4 of the time hmit provided m Govemment Code;§91,1 2 ^1 As stated in the"attached:claim, elamiants' cause-of action accrued on or about December 2;20'O5Ir 2 The rime,for presen Cation of such'claim"under Government Code §911.2 expired; on or about May'3If 1;.2006 3 The reason for.the failure to present suchclaim.withm the time"provided`under Government Code §911:2 was as�follows `-.Claimants, Loreen H lace and-MatthewJace, a mmof,did not retam counsel urittl July 17, 2006 At no time prior to said date'Were claimants aware of the rime constraints provided- r $ "Government Code Said claitri was'prepared for service'as soori_as counsel'discovered that.a cause of action"existed`against.tlie public entity, Contra Costa•County,Regional'Medtcal'` `,,Center: -�No prejudice or change of eircumstance to the,defe'rdant fro' the late claim is known'to -these.claimants. I certify,-,and declare under penalty of per"fury under the laws of the State of California that -'the br&gomg'is true and correct, "Executed this 'Z,c2- day of July, 2006 atWalnut Creek, California Brian' vans T Attorney for Claim ants,•Loreen H Jace and ` Matthew Jace v LY• Two'Walnut Creek Ce ter 200.Pnngle Avenue c Suite 350:0 Walnut Creek CA 94596 r T lephone 925.937 4224 G Fax;925 93,7 4273_ 1 t i4 ..o i U Ca ® ED ® (1.1 fl.lLo Co. i p O M. m ® C3 i r co r.. U) + , m S� � O 1. c Q ami w U s O r�nn T Vdy{ I'I. .I C'I+• i� - U � y 7.r CL 0 0 - ® U ®® CO ti uU o o to o UU �o � v M v ,� r-1 U p O 4i C �.� m 3 C3 0 Lo f` o `n r � N (n 4- � m a O 0 �o j C i