HomeMy WebLinkAboutMINUTES - 06122007 - C.22 CLA1N4
BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY
BOARD ACTION: JUNE 12, 2007
Claim Against the County,or District Governed by )
the Board of Supervisors,Routin Endorsements, ) NOTICE TO CLAIMANT
and Board Action. All Section to et�ce re t
LPJ� ) The copy of this document mailed to
California Government Codes. ) you is your notice of the action taken
MAY 10 2007 on your claim.by the Board of
Supervisors. (Paragraph IV below),
COUNTY COUNSEL given Pursuant to Government Code
MARTINEZ CALIF.
AMOUNT: EXCESS OF $75,000.00 Section 913 and 915.4 .Please note all
"Warnings".
SAUL' CALDERON, MARINA CALDERON
CLAIMANT: AND EDWIN CALDERON
ATTORNEY: THOMAS J. TRACHUK DATE RECEIVED: MAY 10, 2007
ADDRESS: 1999 HARRISON STREET, STE.B70(DELiVERY TO CLERK ON: MAY 10, 2007
OAKLAND, CA 94612
BY MAIL POSTMARKED: MAY 09, 2007
FROM: Clerk of the Board of Supervisors T0: County Counsel
Attached is a copy of the above-noted claim.
MAY 19i; 2007 JOHN CULLEN, er
Dated: By: Deputy
iL FROM.: County Counsel TO: Clerk of the Board of S pervisors
(v)'This claim complies substantially with Sections 910 and 910.2.
( ) This Claim FAILS to comply substantially with Sections 910 and 910.2, and we are so
notifying claimant.The Board cannot act for 15 days(Section 910.8).
( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and
send warning of claimant's right to apply for leave to present a late claim(Section 911-3).
O Other:
Dated. Jr "I O'�� By. 'Mtn eq-gt-avt 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 91 1.3).
I V ARD ORDER: By unanimous vote of the Supervisors present:
l This Claim is rejected in full.
O Other
I certify that this is a true and correct copy of the Board's Order entered in its minutes for
this date.
Dated: /A o V.A)HN CULLEN,CLERK, By Deputy Clerk
WARNWG(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 nail to file a court action on this chain.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 intntediately. *For Additional Warning See Reverse Side of This Notice.
AFFIDAVi.T OF MAILING
I declare under penalty of perjury that i.am now, and at all times herein mentioned, have
been a citizen of the United States, over age 18; and that today I deposited in the United
States Postal Service in Martinez, California, postage fully prepaid a certified copy of this
Board Order and Notice to Claimant,addressed to the claimant as shown above.
Dated: t t c>�O JOHN CULLEN,CLERK By Deputy Clerk
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This warning does not apply to claims which
are not subject to the California Tort Claims
Act such as actions in inverse condemnation,
actionsIfor specific relief such as.mandamus or
injunction, or Federal Civil Rights claims. The
abovellist is not exhaustive and legal
consultation is essential to understand all the
separate limitations periods that may apply.
The limitations period within which suit must
be tiled!may be shorter or longer depending on
I the nature of the claim. Consult the specific
statutes and cases,applicable to your particular
claim.
The County of Contra Costa does not waive any
of its rights under California Tort Claims Act
nor.does it waive rights under the statutes of
dimitati.ons applicable to actions not subject to
the California Tort Claims Act
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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.
(Code.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: Reserved for Clerk's filing stamp
SAUL CALDERON,MARINA CALDERON ) RECEIVED
and EDWIN CALDERON . )
Against the County of Contra Costa or )
MAY 1 0 2001
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$Excess of$75,000 and in support of this claim represents as follows:
1. When did the damage or injury occur? (Give exact date and hour)
November 17,2006, 10:30 p.m.
2. Where did the damage or injury occur? (Include city and county)
At the intersection/crosswalk of Willow Pass Road and Bella Vista Avenue adjacent to the Casa
Del Alfarero Church and bus stop.
3. How did the damage or injury occur? (Give full details; use extra paper if required)
Claimants Saul and Marina Calderon were struck by a vehicle in the uncontrolled crosswalk
suffering serious physical injuries and emotional distress. The collision was witnessed by
claimants' son,Edwin Calderon, causing emotional distress.
4. What particular act or omission on the part of county or district officers, servants, or employees
caused the injury or damage?
On said date and time, Contra Costa County owned, maintained and controlled the intersection of
Willow Pass Road and Bella Vista Avenue and its approaches and configuration which were
unsafely, inadequately and dangerously designed, maintained and operated, including but not
limited'to unsafe, absent and/or inadequate: signage, roadway stripping and markings, site
distances, speed regulations, street lighting and illumination,traffic controls, including the absence
of signalization or stop sign controls, pedestrian crossing signs and other warning devices
necessary for the safety and protection of pedestrians using the crosswalk to access the adjacent
church and bus stop,thereby creating and/or maintaining a dangerous condition of public property
for which the County had actual and/or constructive notice prior to the subject accident.
5. What are the names of county or district officers, servants, or employees causing the damage or
injury?
Unknown at this time.
6. What damage or injuries do your claim resulted? (Give full extent of injuries or damages claimed.
Attach two estimates for auto damage)
(a) Marina Calderon suffered multiple injuries requiring hospitalization and medical treatment
causing permanent disability and economic loss.
(b) Saul Calderon suffered multiple injuries requiring hospitalization and medical treatment
causing permanent disability and economic loss.
(c) Edwin Calderon suffered general and special damages for severe emotional distress from
witnessing his parents' accident and injuries.
7. How was the amount claimed above computed? (Include the estimated amount of any prospective
injury or damage.)
General and special damages for medical expenses and income loss exceed $25,000 for each
claimant.
8. Names and addresses of witnesses, doctors, and hospitals:
Please refer to CHP Traffic Collision Report No. 11-245, attached.
9. List the expenditures you made on account of this accident or injury:
DATE TIME AMOUNT
1
From 11/17/2006 to the present $In excess of$25,000
and continuing
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 ) j'
r
4
Claimant's Signature)
Thomas J.Trachuk
DANG and TRACHUK
1999 Harrison Street
Suite 700
Oakland, CA 94612
Telephone No. )Telephone No.: (510) 874-4113
❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
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.
❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
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.
PROOF OF SERVICE
I am a citizen of the United States and am employed in the County of Alameda, State of California.
I am over eighteen(18)years of age and not a party to the above-entitled action. My business address is
1999 Harrison Street, Suite 700,Oakland,CA 94612. On the date below, I served the following documents
in the manner indicated on the below-named parties and/or counsel of record:
CLAIM AGAINST THE COUNTY OF CONTRA COSTA
X OVERNIGHT: By placing a true copy in a sealed envelope,addressed to the interested parry and
depositing said envelope in the box regularly maintained by the overnight courier service at 1999
Harrison Street,Oakland,California
Clerk
Board of Supervisors
Room 106
County Administration Building
651 Pine Street
Martinez,CA 94553
I declare under penalty of perjury under the laws of the State of California that the foregoing is true
and correct and that I am readily familiar with this firm's practice for collection and processing of
documents for delivery by the overnight courier.
EXECUTED on May 9,2007,at Oakland,California
Glo ' Bermu ez-Buruato
Proof of Service
DANG and TRACHUK
Attorneys At Law
1999 Harrison Street
Suite 700
Oakland,California 94612
Douglas Y. Dang(1942-2006) Telephone(510)874-4113
Thomas J.Trachuk Fax(510)287-4050
Michael J.Greathouse
May 9, 2007 RECEIVED
VIA EXPRESS MAIL MAY 1 0 2007
Clerk CLERKRD OF CONTRA C STA CO.SUPERVISORS
Board of Supervisors
Room 106
County Administration Building
651 Pine Street
Martinez, CA 94553
Re: Claimants: Saul Calderon,Marina Calderon and Edwin Calderon
Date of Accident: November 17,2006
Accident Site: Willow Pass Road and Bella Vista Avenue
Dear Sir/Madam:
Enclosed please find an original and one (1)copy of a claim presented to the County of
Contra Costa which this office is filing on behalf the above-named Claimants.
Please file the original and return the copy stamped filed in the enclosed self-addressed
stamped envelope.
Thank you for your assistance in this matter. If you have any questions regarding the
enclosed,please do not hesitate to contact the undersigned.
Very truly yours,
DANG andTRACHUK
Thomas J. Trachuk
TJT/gb
Enclosure
cc: Saul Calderon
Marina Calderon
Edwin Calderon
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r CLAIM
BOARD OF SUPERVISO.RS OF CONTRA COSTA COUNTY
BOARD ACTION: JUNE 12, 2007
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 cry of this document mailed to
California Government Codes. ) - you-i�your notice of the action taken
CLAIM AGAINST MERRITHEW MEMORIAL HOSPITAL c.on your claim.by the Board of
NOTE: NO ATTACHMENTS RECEIVED. ; �pervisors. (Paragraph IV below),
�;. 1 ggq en Pursuant to Government Code
AMOUNT: $1,000,000. MAY 1 8 2007 ction 913 and 915.4. Please note all
Warnings".
CLAIMANT: SCOTT A. JARAMILLO COUNTY COUNSEL
P!lARTINEZ CALIF.
ATTORNEY: UNKNOWN DATE RECEIVED: MAY 18, 2007
ADDRESS: P.O. BOX 1296 BY DELIVERY TO CLERK ON: MAY 18, 2007
OAKLEY, CA 94561
BY.MAIL POSTMARKED: HAND DELIVERED
FROM: Clerk of the Board of Supervisors TO: County Counsel
Attached is a copy of the above-noted claim.
MAY 18JOHN CULLEN, C
, 2007 le
Dated: By: Deputy
I.I. FROM.: County-Counsel TO: Clerk of the Board of Sup visors
(1, his claim complies substantially with Sections 910 and 910.2.
( ) This Claim FAILS to comply substantially with Sections 9.10 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 retu7h claim on ground that it was filed late and
send waining of claimant's right to apply for leave to present a late claim (Section 91. 1.3).
O Other:
Dated: By: Deputy County Counsel
Ill. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2)
( ) Claim was returned as untimely with notice to claimant (Section 911.3).
(IV. ARD ORDER: By unanimous vote of the Supervisors present:
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 . /a JZO HN CULLEN, CLERK, By eputy Clerk
WARKING (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 nuail 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. tf you want to consult an
attontey,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 I\'tartinez, California, postage fully prepaid a certified copy of this
Board Order and Notice to Claimant, addressed to the claimant as shown above.
Dated: /� -e `a�70HN CULLEN, CLERK By -Beputy Clerk
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This warning does not apply to claims which
are not subject to the California Tort Claims
Act such as actions in inverse condemnation,
action's for specific relief such as. mandamus or
injunction, or Federal Civil Rights claims. The
abovellist is not exhaustive and legal
consultation is essential to understand all the
separate limitations periods that may apply.
The limitations period within which suit must
be filed may be shorter or longer depending on
the nature of the claim. Consult the specific
statutes and cases applicable to your particular
claim.'
jI
The County of Contra Costa does not waive any
of its rights under California Tort Claims Act
:!nor does it waive rights under the statutes of
limitations applicable to actions not subject to
the California Tort Claims Act
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BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY
INSTRUCTIONS TO CLAIMANT
A. A claim relating to a cause of action for death or for injury to person or to personal property or
growing crops shall be presented not later than six months after the accrual of the cause of
action. A claim relating to any other cause of action shall be presented not later than one year
after the accrual of the cause of action.
(Gov. Code § 911.2.)
B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 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.
Noun Monosson MWERNMENNENEW Nnumm"WommooNonone son noMI
RE: Claim By: Reserved for Clerk's filing stamp
Against the County of Contra Costa or ) �ECEIVE®
MAY 1 8 tuu i
District)
(Fill in the name) )
CLERK BOARD OF SUPERVISORS
CONTRA COSTA CO.
The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named
district in the sum of$ 1 C16 0i 0 4S�� and in support of this claim represents as follows:
1. Wh n did the damage or injury occur? (Give exact date and hour)
Y`n
2. Where did the damage or injury occur? (Include city and county)
-e''r, A-c a' A / j� � ,��
C r L
3. ,.—How dill the damage or injury occur? (Give full details; use extra paper if required)
l r`_,..s Y�� t� r� {.�y. t:•�ay �;� �a C:-�w 1 s �f ,4 c_.SY�r•��� t� �- �c �,—
a(� e. ��,�„ �. 4�i >1/�c:-� ��.ti i�J c��✓:�
4. What particular act or omission on the part of co my or district officers, servants, or employees
caused the injury or damage?
otoCSE reo, t.d y ►y fi%�/irl
Stir r y � g s TI-C. t
� �t
-;c Ili yS`iti � C . � �</ti i✓� 7��'
5 . What are the names of count dr�istrict officers servants or em to exes causin the
Y P Y g
damage or injury? y`V CL W
6. What damage or injuries do your claim resulted? (Give full extent of injuries or damages
claimed. Attach two estimates for auto damage.)
r? �� C,
7. How was the amount claimed above computed? (Incline the estimated amount of any
prospective injury or damage.) inti c1 :���.r`.S�u zr'-e—
Of
8. Names and addresses of witnesses,doctors, and hospitals:
Tefj �_�c eco., L(:7 �w�'4?, LI",Se
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
n ) (Claimant's Signature)
L )—T (Address)
G c�IL1
Telephone No./ �D `���� � T� )Telephone No.
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.
....................s................................■........:............. ....Ems.R
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.
CLAIM
BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY
BOARD ACTION: JUNE 12, 2007
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 SHERIFF'WORK ALT. P OG Su%�ervisors. (Paragraph IV below),
D grvet� Pursuant to Government Code
Section 913 and 915.4. Please note all
AMOUNT: $1,000,000. MAY 18 200/"Warnings".
CLAIMANT: SCOTT A. JARAMILLO COUNTY COUN-SEL
P.4ARTINEZ CALIF.
ATTORNEY: UNKNOWN DATE RECEIVED: MAY 18, 2007
ADDRESS: P.O. BOX 1296 BY DELIVERY TO CLERK ON: MAY 18, 2007
OAKLEY-, CA 94561
BY MAIL POSTMARKED: HAND DELIVERED
FROM: Clerk of the Board of Supervisors TO: County Counsel
Attached is a copy of the above-noted claim.
MAY 18, 2007 . JOHN CULLEN, r
Dated: By: Deputy
I.I. FROM.: County-Counsel TO: Clerk of the Board of Sufervisbrs
( lhis 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 retum 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: 5 / By: Deputy County Counsel
ill. FROM.: Clerk of the Board TO: County Counsel.(1) County Administrator (2)
( ) Claim was returned as untimely with notice to claimant (Section 911.3).
(I.V. ARD ORDER: By unanimous vote of the Supervisors present:
This Claim is rejected in full.
O Other:
I certify that this is a true and correct copy of the Board's Order entered in its minutes for
this date.
Dated: -Z �J< fN CULLEN, CLERK, By eputy Clerk
WARMNG (Gov. code section 913) Ir
Subject to certain exceptions,you have only six(6) months from the date this notice was personally served
or deposited in the nuail to file a court action on this claainh.See Government Code Section 945.6.You may
seek the advice of an attorney of your choice in connection with this matter. tf 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 Ntartinez, California, postage fully prepaid a certified copy of this
Board Order and Notice to Claimant, addressed to the claimant as shown above.
Dated: AfAAF JOHN CULLEN, CLERK By eputy Clerk
i
This warning does not apply to claims which
are not subject to the California Tort Claims .
Act Stich as actions in inverse condemnation,
actions for specific relief such as. mandamus or
injunction, or Federal Civil Rights claims. The
above list is not exhaustive and legal
consultation is essential to understand all the
separate limitations periods that may apply.
The limitations period within which suit must
be filed may be shorter or longer depending on
the nature of the claim. Consult the specific
statutes and cases applicable to your particular
claim.:
The County of Contra Costa does not waive any
of its rights under California Tort Claims Act
nor does it waive rights under the statutes of
limitations applicable to actions not subject to
the California Tort Claims Act
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BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY
INSTRUCTIONS TO CLAIMANT
A. A claim relating to a cause of action for death or for injury to person or to personal property or
growing crops shall be presented not later than six months after the accrual of the cause of
action. A claim relating to any other cause of action shall be presented not later than one year
after the accrual of the cause of action.
(Gov. Code § 911.2.)
B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106,
County Administration Building, 651 Pine Street, Martinez, CA 94553.
C. If claim is against a district governed by the Board of Supervisors, rather than the County, the
name of the District should be filled in.
D. If the claim is against more than one public entity, separate claims must be filed against each
public entity.
E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at the end of this form.
RE: Claim By: Reserved for Clerk's filing stamp
ei 7Vi l
)
Against the County of Contra Costa or )
RECEIVE®
District] MAY 1 8 cuU/
(Fill in the name) j CLERK BOARD OF SUPERVISORS
CONTRA COSTA CO.
The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named
district in the sum of$ (;on and in support of this claim represents as follows:
1. When did the damage or injury occur? (Give exact date and hour)
2- 0 4)
2. W, hyre did the damage or injury occur? (Include city and county)
Iy
3. How did the damage or injury occur? (Give. full, idetails; use extra a)eIke hc�cr if required)
c y �r_ �
%✓� �/ rr� 6✓';S 7 w Shea ����f I � w � � � l� � _
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? C� , ter 5���: �« Z Z
6. What damage or injuries do your claim resulted? (Give full extent of injuries or damages
claimed. Attach two estimates for auto damage.) I L
y
7. How was the amount claimed above computed? (Include the estimated amount of any
prospective injury or damage.)
) S(,,�4r-:y.�, / LA k/l e.
8. Names and addresses of witnesses, doctors, and hospitals:
9. List the expenditures you made on account of this accident or injury:
DATE TIME AMOUNT
............................................................................ . ..Mason$
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 )
(Claimant s Signature)
0 e-,X/-e (Address)
C'.- n y r,0
Telephone No 1%4 ) Telephone No.
■..e.................................................■.....................■ ■.......l
PUBLIC RECORDS NOTICE:
Please be advised that this claim form, or any claim filed with the County under the Tort Claims Act, is subject to
public disclosure 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.
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.
cLArivr G/
BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY
BOARD ACTION: JUNE 12, 2007
Claiilr 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
WKSupervisors. (Paragraph IV below),
D given Pursuant to Government Code
AMOUNT: $350.00 MAY 1 8 2007 Dul Section 913 and 915.4. Please note all
"Warnings".
COUNTY COUNSEL
CLAIMANT: DAVID K. KUBO MARTINEZ CALIF
ATTORNEY: UNKNOWN DATE RECEIVED: MAY 18, 2007
ADDRESS: 1220 DIANA AVENUE, BY DELIVERY TO CLERK ON: MAY 18, 2007
MORGAN HILL, CA 95037
BY MAIL POSTMARKED: MAY 17, 2007
FROM: Clerk of the Board of Supervisors TO: County Counsel
Attached is a copy of the above-noted claim.
JOHN CULLEN, r
Dated: MAY 18, 2007 By: Deputy
iI. FROM: County Counsel TO: Clerk of the Board of Su ervisors
( his claim complies substantially with Sections 910 and 910.2.
( ) This Claim FAILS to comply substantially with Sections 910 and 910.2, and we are so
notifying claimant. The Board cannot act for 15 days (Section 910.8).
( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and
send warning of claimant's right to apply for leave to present a late claim (Section 911.3).
O Other:
Dated: Jr_ �— d 7 By: ITCZL& � 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).
(1V. ARD ORDER: By unanimous vote of the Supervisors present:
This Clairn 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: �/O? JOIN CULLEN, CLERK, By eputy Clerk
WAR ING (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 chiim.See Government Code Section 945.6.You may
seek the advice of an attorney of your choice in connection with this matter. rf'you want to consult an
attorney,you should do so inurrediately. *For Additiwal Wanihw,See Reverse Side of'Tlris Notice.
AFFIDAVIT OF MAILING
I declare under penalty of perjury that i. am now, and at all times herein mentioned, have
been a citizen of the United States, over age 18; and that today I deposited in the United
States Postal Service in Martinez, California, postage fully prepaid a certified copy of this
Board Order and Notice to Claimant, addressed to the clainran.t as shown above.
Dated: �/3 .?.,Av.?'JOHN CULLEN, CLERK By eputy Clerk
i
R
This warning does not apply to claims which
are not subject to the California Tort Claims
Act such as actions in inverse condemnation,
actions for specific relief such as mandamus or
injunction, or Federal Civil Rights claims. The
above"list is not exhaustive and legal
consultation is essential to understand all the
separate limitations periods that may apply.
The limitations period within which suit must
be tiled may be shorter or longer depending on
the nature of the claim. Consult the specific
statutes and cases applicable to your particular
claim.
The, County of Contra Costa does not waive any
of itis rights tinder California Tort Claims Act
n.or I(toes it waive rights under the statutes of
,limitations applicable to actions not subject to
the California Tort Claims Act
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Claim to: BOARD OF SUPERVLSORS OF CONTRA COSTA COUNTY
INSTRUCTIONS TO CLAIMANT
A. Claims relating to causes of action for death or for injury to person or to per-
sonal property or growing crops and which accrue on or before December 31, 19872
must be presented not later than the 100th day after the accrual of the cause 'of
action. Claims relating to causes of action for death or for injury to person
or to personal property or growing crops and which accrue on or after January 1,
1988, must be presented not later than six months after the accrual of the cause
of action. Claims relating to any other cause of action must be presented not
later than one year after the accrual of the cause of action. (Govt. Code §911.2.)
B. Claims must be filed With the Clerk of the Board of Supervisors at its office in
Room 106, County Administration Building, 651 Pine Street, Martinez, CA 94553•
C. If claim is against a district governed by the Board of Supervisors, rather than
the County, the name of the District. should .be filled in.
D. If the claim is against more than one public entity, sepearate claims mist be
filed against each public entity.
E. Fraud. See penalty for fraudulent claims., Penal Code Sec. 72 at the end of this
?-Or—m.
RE: Claim By ) Reserved for Clerk's filing stamp
�2-iv iv
RECEIVED
M )IC64A/ /7-'i// ,
Against the County of Contra Costa ) MAY 1 8 2001
or )
CLERK BOARD OF SUPERVISORS
District) CONTRA COSTA CO.
Fill in name )
The undersigned claimant hereby makes claim against the County of Contra Costa or
the above-named District in the sum of $ � .�- and in support of
this claim represents as follows:
1. When did the damage or injury occur? (Give exact date and hour)
0 -7
2. Where did the damage or injury occur? (Include city and county)
C)�� s�vu7k A) E �J � M13P-111A
3. How did the damage or injury occur? (Give full details; use extra paper if M
required)
4. What particular act or emission on the part of county or district officers,
servants or employees caused the injury or damage?
T(E),iv q M 2a,t +D +-h
p-11-L L�: ('u I I n, 1 4 .S a wPA
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5. What are the names oflcounty or district ofi'icers, servants or emp.ioyees causing
the damage or- in,jury?
6. What damage or injuries do you claim resulted? (Give full extent of injuries or
damages claimed. Attach t� tes or auto damage.
---
7. How was the amount claimed above 'computed? (Include the estimated amount of any
prospective injury or ;damage.)
8. Names and addresses of witnesses, doctors and hospitals.
cy- leu
�U G�
_� ----------- ' ---------------------------------------------
9. List the expenditures you made on account of this accident or injury:
i DATE ITEM AMOUNT
Gov. Code Sec. 910.2 provides:
"The claim must be signed by the claimant
SEND NOTICES TO: (Attorney) or by some person on his behalf."
i
Name and Address of Attorney
jClaimant's Signature
Addre
� Telephone No. I Telephone No.
NOTICE
Section 72 of the Penal Code provides:
i
"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 ane 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'lof not exceeding ten thousand dollars ($10,000, or by
both such imprisonment and fine.
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