HomeMy WebLinkAboutMINUTES - 04152008 - C.13 i
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CLAIM
BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY
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j BOARD ACTION:
Claim Against the County, or District Governed by )
the Boai•d of Supervisors, Routing Endorisements, ) NOTICE TO CLAIMANT
and Board Action. All Section i-efei•ences are to ) The copy of this document mailed to
California Government Codes. To?�6 E7�� you is your notice of the action taken
!!!!1111 on your claim.by the Board of
MAR 2 1 2608 Supervisors. (Paragraph IV below),
COUNTY COuNSk given Pursuant to Government Code
E�CCEEDS 25� IddRTINEZCALIF. Section 913 and 915.4. Please note all
AMOUNT: �I "Warnings".
CLAIMANT: ADRIAN( AR20YO
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ATTORNEY: MIA-nEW DATE RECEIVED: V400d rli=
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ADDRESS: 113(, Tt A BY DELIVERY TO CLERK ON: ROAR 1-71
M�Q.TIZ, CA q4 BY MAIL POSTMARKED: A!A
FROM: Clerk of the Board of Supervisors TO: County Counsel
Attached is a copy of the above-noted claim.
JOHN CULLS Clerk AA''
Dated: �N�Zf ZL j By: Deputy lie�50f)
Il. FROM: County Counsel TO: Clerk of the Board of Supervisors
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( >41iis claim complies substantially1with Sections 910 and 910.2.
( ) This Claim FAILS to comply substantially with Sections 910 and 910.2, and we are so
notifying claimant. The Board cannot act for 15 days (Section 910.8).
( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and
send warning of claimant's right to apply for leave to present a late claim (Section 911-3).
( ) Other:
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Dated: 3' �'7 p By: Deputy County Counsel
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ill.. FROM: Clerk of the Board T0: County Counsel (1) County Administrator(2)
( ) Claim was returned as untimely with notice to claimant (Section 911.3).
IV. BOARD ORDER: By unanimous vote of the Supervisors present:
XThis Claim is rejected in full.
( ) Other:
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I certify that this is a true and con-ect copy of the Board's Order- entered in its minutes foi-
this date.
Dated: o JOHN CULLEN, CLERK, yDepu lerk
WARNING Gov. code section 913)
Subject to certain exceptions,you have only six(6) months from tine ate nis notice was personally served
or deposited in the nnail 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 Additiaial Warning See Reverse Side of This Notice.
AFFIDAVIT OF MAILING i
I declare-under penalty of perjury Ithat 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.
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Dated: 6CkJOHN CULLEN, CLERK By Deputy Clerk
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CLAIM
BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY
BOARD ACTION: AmI-A ag Pg
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: E1C�ED$ . 26� '� Section 913 and 915.4. Please note all
"Warnings".
CLAIMANT: ADRW&N AR9-0Y0
ATTORNEY: MIA'RNEW T. FRECM: DATE RECEIVED:
ADDRESS: BY DELIVERY TO CLERK ON:
AX-Z, CA qy BY MAIL POSTMARKED: Al A
FROM: Clerk of the Board of Supervisors TO: County Counsel
Attached is a copy of the above-noted claim.
JOHN CULLS , Clerk
Dated: l401MQI elf By: Deputy ERe�leLeon
11. FROM.: County Counsel TO: Clerk of the Board of Supervisors
( ) This claim complies substantially with Sections 91.0 and 910.2.
( ) This Claim FAILS to comply 'substantially with Sections 910 and 910.2, and we are,so
notifying claimant. The Board cannot act for 15 days (Section 910.8).
( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and
send warning of claimant's right to apply for leave to present .a late claim (Section 911.3).
( ) Other:
Dated: By. Deputy County Counsel
III. FROM: Clerk of the Board TO:. County Counsel (1) County Adrninistrator(2)
( ) Claim was returned as untimely with notice to claimant (Section 911.3).
IV. BOARD ORDER: By unanimous vote of the Supervisors present:
( ) This Claim is rejected in full'.
( ) Other:
I certify that this is a true and correct copy of the Board's Order entered in its minutes for
this date.
Dated: JOHN CULLEN, CLERK, By Deputy Clerk
WARNING (Gov. code section 913)
Subject to certain exceptiois,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 play
seek the advice of an attorney of your choice in connection wide this matter. If you want to consult an
attorney,you should do so hnmediately. *For Additional Warning See Reverse Side of liis 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 tine United
States Postal Service in Martinez, California, postage fully prepaid a certified copy of this
Board Order and Notice to Clainiant, addressed to the claimant as shown above.
Dated: JOhN CULLEN, CLERK By Deputy Clerk
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MATTHEW J. FREGI, State Bar No.239525
1 Attorney at Law
1136 Henrietta Street
2 Martinez, California 94553
(925)565-3456 RECEIVE®
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ATTORNEY FOR CLAIMANT ry Jas
4 ADRIAN ARROYO MAR 1 c
5 CLERK BOARD OF SUPERVISORS
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CONTRA COSTA CO.
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ADRIAN ARROYO,
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Plaintiff,'
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VS. GOVERNMENT TORT CLAIM BY
9 COUNTY OF CONTRA COSTA; ADRIAN ARROYO
10 MARTINEZ DETENTION FACILITY; [Goverrunent Code § 910]
DEPUTY RECTOR, #70610; DEPUTY
I JONES, #71163; DEPUTY CONIGLIO, #
(unknown); and DOES 1 TO 100, inclusive. Action Filed: Suit Not Yet Filed
12 , Trial Date: None Yet
Defendant. /
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16 I. CLAIMANT
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ADRIAN ARROYO
18 2609 Fairmont Lane
Antioch, California 94509
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20 II. PERSON TO WHOM NOTICES ARE TO BE SENT
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21 ROSE ARROYO
2609 Fairmont Lane
22 Antioch, California 94509
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ISI. DATE, PLACE, AND THE TIME OF THE OCCURRENCE
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25 Evening of September 30, 2007
Martinez Detention Facility
26 Q Module, Upper Tier
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GOVERNMENT TORI'CLAIM
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2 IV. OCCURRENCE
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3 The deputies involved claimed to have been conducting random room checks on the evening
a f September 30, 2007. Despite the proclaimed random nature of the room checks, Deputy
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s Rector"chose" to search claimant's cell. Prior to conducting his search, Deputy Jones escorted
6 claimant down to the shower area. Claimant had on his person some "scrolls", which are
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nauthorized to possess in the jail. Claimant attempted to dispose of these scrolls by placing the
n his mouth and swallowing them. Deputy Jones was hip to claimant's attempt, and quickly
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laced claimant in a choke hold, preventing claimant from successfully swallowing the paper.
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Deputy Jones states that he witnessed 'claimant empty his mouth as he successfully brought
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laimant to his belly and applied cuffs. At this point, subsequent to claimant being subdued in
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I` laiinant's back so that claimant's freedom of movement was completely restricted. Deputy
13 Rector took his police issued 18 inch steel flashlight and began to smash claimant about his side
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Ia and oblique area. Deputy Rector then began to dig the end of the flashlight in claimant's side
15 my to drag it along his flesh. Deputy Rector did this with all of his might causing demonstrable
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16 njury to claimant's side. All claimant could do while this was taking place was cry and scream i
17 ain and beg the deputy to stop. There were several witnesses to the incident, as well as several
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photographs taken by medical personnel who treated claimant. Claimant is awaiting the results o
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n MRI and is experiencing a great deal of pain, accompanied by a tingling sensation down the
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ntire side of his body. His treating physician suspects permanent damage to claimant's nerves
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n account of Deputy Rector's senseless attack. In addition, claimant suffered severe emotional
21 istress on account of the severe beating he endured at the hands of Deputy Rector.
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23 V. PUBLIC EMPLOYEES CAUSING INJURY OR DAMAGE
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24 Claimant identifies as the following members of the Contra Costa Sherriff's Department:
25 EPUTY RECTOR, # 70610, DEPUTY JONES, # 71163, DEPUTY CONIGLIO, (unknown).
26 Claimant reserves the right to identify further employees as their identities become known.
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GOVERNMENT TORT CLAIM
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VI. UNLIMITED CIVIL JURISDICTION
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The extent of claimant's damages lexceeds $2 ,000.00, so this action would properly be
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ithin the unlimited civil jurisdiction of the State Courts if the action is filed in State Court. The
4 action will also be within the jurisdiction of the United States District Court for the Northern
District of California.
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7 Dated: February 20, 2008 Respectfully submitted,
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9MATTHEW . FRE
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1 o Attorney for imant
ADRIAN ARROYO
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GOVERNMENTTORT CLAIM
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CLAIM -3
BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY
BOARD ACTION:
April 15, 2008
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),
MAR 212008 given Pursuant to Government Code
AMOUNT: $ 10,000.00 1 Section 913 and 915.4. Please note all
CbuNTY coU'NSEL "Warnings".
MARTINEZ CALIF.
CLAIMANT: Deborah Hubbert
A"I'TORNEY: N/A
DATE RECEIVED: March 7 2008
ADDRESS: 2900 The Alameda BY DELIVERY TO CLERK ON: March 7, 2008
Concord, CA 94519
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BY MAIL POSTMARKED: N/A
FROM: Clerk of the Board of Supervisors T0: County Counsel
Attached is a copy of the above-noted claim.
March 10, 2008 JOHN CULLEN, Cnle,i�•k
Dated: By: Deputy CP_L Li C& kk SoY
11. FROM: County Counsel TO: Clerk of the Board of Supervisors
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(. his claim complies substantially with Sections 910 and 910.2.
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( ) This Claim FAILS to comply substantially with Sections 910 and 910.2, and we are so
notifying claimant. The Board cannot act for.15 days (Section 910.8).
( .) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and
send warning of claimant's right to apply for leave to present a late claim (Section 911.3).
( )
Other:
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Dated: oZ 7'OP By: m Deputy County Counsel
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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. BOARD 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.
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Dated: o JOHN CULLEN, CLERK, By Deputy Clerk
WARNING Gov. code section 913)
Subject to certain exceptions,you have only six(6) months from Zdate 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 widr this matter. If you want to consult an
attorney,you should do so immediately. *For Additional Warring,See Reverse Side ofTrris Notice.
AFFIDAVIT OF MAILING
I declare under penalty of per jury that 1. 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 Clainiant, addressed to the claimant as shown above.
Dated: �o m JOHN CULLEN, CLERK By Deputy Clerk
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1 CLAIM
HOARD OF SUPERVISORS OF CONTRA COSTA COUNTY
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BOARD ACTION: April 15-2008
Claim Against the County, or District Governed by )
the Boai•d 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),
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given Pursuant to Government Code
AMOUNT: $ 10,000.00 Section 913 and 915.4. Please note all
"Warnings".
CLAIMANT: Deborah Hubbert 1
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ATTORNEY: N/A DATE RECEIVED:
March 7, 2008
ADDRESS: 2900 The Alameda i BY DELIVERY TO CLERK ON:
March 7, 2008
Concord, CA 945191
BY MAIL POSTMARKED: N/A
FROM: Clerk of the Board of Supervisors TO: County Counsel
Attached is a copy of the above-noted claim.
March 10, 2008 1 JOHN CULLEN, Clerk ,, 11--//
Dated: By: Deputy CCICIC._/A(&4!)
II. FROM.: County Counsel 'TO: Clerk of the Board of Supervisors
( ) This claim complies substantially with Sections 910 and 9.10.2.
( ) This Claim FAILS to comply Isubstantially with Sections 910 and 910.2, and.we are so
notifying claimant. The Board cannot act for 15 days (Section 910.8).
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( ) Claim is not timely filed. The G,lerk 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).
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( ) 0th"er:
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Dated: 1 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).
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IV. BOARD ORDER: By unanimous vote of the Supervisors present:
( ) This Claim is rejected in full!
( ) Other: 1
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I certify that this is a true and correct copy of the Board's Order entered in its minutes fol•
this date. 1
Dated: JOHN CULLEN, CLERK, By Deputy Clerk
WARNING (Gov. code section 913) ,
Subject to certain exceptions,you havelonly six(6) months from the date this notice was personally served
or deposited in the mail to file a court aIetion on this claim.See Government Code Section 945.6.You may
seek the advice of an attorney of your choice in connection wide this matter. If you want to consult an
attorney,you should do so immediately. *For Additional Warning See Reverse Side ofThis Notice.
AFFIDAVIT OF MAILING I
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 N/lartinez, California, Hostage fully prepaid a certified copy of this
Board Order and Notice to Claimant, addressed to the clainian.t as shown above.
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Dated: JOHN CULLEN, CLERK By Deputy Clerk
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RECEIVED �R,
R E C E _�D
MAR " 20[ O OF SUPERVISORS OF CONTRA COSTA CO
INSTRUCTIONS TO CLAIMANT MAR 2008
CLERK BOARD OF SUPERVISORS
CO Tn iRA a cause of action fof death or for injury to person or to we
' ^ `P� VISORS
growing crops shall be presented not later than six months after the ac o c��G;'t'�'A�
action.. A claim relating to any other cause of action shell 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 elitity.
E. Emud. See penalty for fraudulent claims, Penal Code Sec. 72 at the end of this form.
Soong a mannowiffisone on onoudgme Boom psomeffive bass Imag"ago Depose of
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RE: Claim By: Reserved for Clerk's filing stamp
Deborah Hubbert )
2900 The Alameda )
Concord, Ca. 9451.9 }
Against the County of Contra Costa or )
)
District)
(]Fill in the name) )
The undersigned claimant hereby makes clean against the County of Contra Costa or the above-named
district in the sum of$,� see below pnd in support of this claim represents as follows:
In excess of $ 10,000.00 . ;
1. When did the damage or injury occur? (Give exact date and hour)
September 11, 2007 PM and! September 13, 2007 AM.
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2. Where did the damage or injury occur? (Include city and county)
Martinez Detention Facility, City of Martinez,
County of Contra Costa.
3, How did the damage or injury occur? (Give full details;use extra paper if required)
Excessive unlawful force used by law enforcement officers.
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4. What particular act or omission on the part of county or district officers, servants, or employees
caused the injury or damage?
Excessive and unlawful force used by law enforcement officers.
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5 What are the names of county or district officers, servants, or employees causing the
damage or injury?
Contra Costa County Sherrif ' s Department, particular names
unknown at this time, discovery is continuing.
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6. What damage or injuries do your claim resulted? (Give full extent of injuries or damages
claimed. Attach two estimates for auto damage.)
Neuroligical damage, Ophthalmological damage, Hematomas and
Emotional distress.
7. How was the amount claimed above computed? (Include the estimated amount of any
prospective injury or damage.)
Amount claimed will be in excess of $10,000 .00y the total amount
is un)�nq�an at $hI s timgd treatRent�s ongoing and discovery is continuing.
&. Names an addresses o WltuesseS, OCtOrS,'an ospl S:
John Muir Medical Center, Walnut Creek Campus Emergency Physicians
Discovery is continuing
9. List the expenditures you made on account of this accident or injury:
DA TTIvIE AMOUNT_
The total amount is unknown at this time. Discovery is continuing,
mean*smogs*rrr*@**r@age goes rre*@rr*Arrrri*rrrrrrrrrrrrrrrrrtrrrsrrlrrrrr fps rrrrrrrr*ri
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Gov.Code Sec. 910.2 provides"The claim shall be
signed by the claimant or by some person on his
) behalf."
SEND NOTICES T0: (Ayorneyy )
Name and address of Attorney 1)
(Claimant's Signature)
2900 The Alameda, Concord, Ca. 94519
(Address)
Telephone No. )Telephone No. (9 2 5 ) 525-4393
seems rroMaass$@goner•/errs/rrr*rrrrrrrr'r@ *r*rrrr���rrr�*r��rr�rrrrrrr�*rrrrrr*r*r�*�
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PUBLIC RFA ORDS NOTICE:
Please be.advised that this claim form, or any claim Aled with the County under the Tort Claims Act, is subject to
public disclosure under the California Public Records Act. (Gov. Code, SS 6500 et seq.) Furthermore, any
attachments,addenduros,or supplements attached to the claim form, including medical records,are also subject to
public disclosure.
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NOTICE:
Section 72 of the Penal Code provides.-
Every
rovides.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 ($1,000.04), or by both such
imprisonment and fine, or by imprisoruaent in th'e state prison, by a fine of not exceeding ten tbousand dollars
($10,000), or by both such imprisonment and fine.
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CLAIM ` 3
BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY
BOARD ACTION: April /,2008
Claim Against the County, or District Governed by )
the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT
and Board Action. All Section references are to ) The copy of this document mailed to
California Government Codes. ) you is your notice of the action taken
on your claim by the Board of
gG7 f 11ZV7�
Supervisors. (Paragraph IV below),
given Pursuant to Government Code
MAR 2 1 ZUU$ Section 913 and 915.4. Please note all
AMOUNT: 667.85 COUNTY COUNSEL "Warnings".
MARTINEZ CALIF
CLAIMANT: Tim Honea
N/A March 6, 2008
ATTORNEY: ,' DATE RECEIVED:
ADDRESS: 2945 Short Street BY DELIVERY TO CLERK ON:
March 6, 2008
Oakland Ca 94619
BY MAIL POSTMARKED: N/A
FROM: Clerk of the Board of Supervisors T0: County Counsel
Attached is a copy of the above-noted claim.
JOHN CULLEN, Qeer�k _
Dated: _`1Le/Gh lot -QXS I By: Deputy
11. FROM: County Counsel TO: Clerk of the Board of Supervisors
( "This claim complies substantially with Sections 910 and 910.2.
( ) This Claim FAILS to comply substantially with Sections 910 and 910.2, and we are. so
notifying claimant. The Board cannot act for 15 days (Section.910.8).
( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and
send waming of.claimant's right to apply for leave to present a late claim (Section 911.3).
O Other:
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Dated: ' �� O By: Deputy County Counsel
111. FROM: Clerk of the Board TO: County Counsel (1) County Administrator(2)
( ) Claim was returned as untimely with notice to claimant (Section 911.3).
1V BOARD ORDER: By unanimous vote of the Supervisors present:
This Claim is rejected in full:'
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Other:
I certify that this is a true and correct copy of the Board's Oi-dei• entei-ed in its minutes for
this date.
Dated: 014.1, JOHN CULLEN, CLERK, y uty Clerk
WARNING ( ov. code section 913;)
Subject to certain exceptions,you have only six(6) months from the Lte this notice was personally served
or deposited in the mail to file a court actiat on this chain.See Government Code Sectim 945.6.You may
seek the advice of an attorney of your choice in connection widr this matter. if you want to consult an
attorney,you should do so inunediatefy. *For Additional Warning,See Reverse Side ofThis Notice.
AFFIDAVIT OF MAILING
I declare under penalty of perjury that i ani 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.Claiiiiant, addressed to the claimant as shown above.
Dated: JOHN CULLEN, CLERK By Clerk
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CLAINI
BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY
BOARD ACTION: April MJ�2008
Claim Against the County, or District Governed by )
the Board of Supervisors, Routing Endorserne.nts, ) 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
Section 913 and 915.4. Please note all
AMOUNT: 667.85 "Warnings".
CLAIMANT: Tim Honea
ATTORNEY: NIA DATE RECEIVED: March 6, 2008
ADDRESS: 2945 Short Street BY DELIVERY TO CLERK ON: March 6 2008
Oakland Ca 94619
BY MAIL POSTMARKED: N/A
FROM: Clerk of the Board of Supervisors TO: County.Counsel
Attached is a copy of the above-noted claire.
///ll JOHN CULLEN, ',Jerk A�G
Dated: Ch ly By: Deputy auuci ► sW
I.I. FROM: County Counsel TO: Clerk of the Board of Supervisors
( ) This claim complies substantially with Sections 910 and 910.2.
( ) This Claim FAILS to comply substantially with Sections 910 and 910.2, and we are so
notifying claimant. The Board cannot act for 15 days (Section 910.8).
( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late. and
send warning of claimant's right to apply for leave to present a late claim (Section 911.3).
( ) Other:
Dated: By: Deputy County Counsel
III. FROM:: Clerk of the Board TO: County Counsel (1) County Administrator (2)
( ) Claim was returned as untimely with notice to claimant (Section 911.3).
IV, BOARD ORDER: By unanimous vote of the Supervisors present:
( ) This Claim is rejected in full.
( ) Other:
i certify that this is a true-and correct copy of the Board's Order- entered in its minutes for
this date.
Dated: JOHN CULLEN, CLERK, By Deputy Clerk
WARNING (Gov. code section 913) ,
Subject to certain exceptions,you have only six(6) months from the date this notice was personally served
or deposited in the ntail to file a count action on this claim.See Government Code Section 945.6.You may
seek the advice of an attomey of your choice in connection with this matter. Ifyou want to consult an
attorney,you should do so immediate -se Additional Wa�ni� Sc'e Reverse Side ofThis Notice.
AFFIDAVIT OF MAILING
I. declare under penalty of perjury that 1. am now, and at all tinnes 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 [viartinez, California, postage fully prepaid a certified copy, of this
Board Order and Notice to Claimant, addressed to the claimant as shown above.
Dated: JOI-IN CULLEN, CLERK By Deputy Clerk
' BOARD OF SLTPERN71SORS OF CONTRA COSTA COUNTY
rISTRUCTIONS TO CLAIMANT'
A. . A claim relating to a cause of action for death or for injury to person or to personal property or
groiN ing 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 94563.
C. If claim is against a district governed by the Board of Supervisors, rather than the County, the
name of the District should be filledin.
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.
[[[■[[[[[■ar[[[[■■[[■■rr[■■[[BROKER[■[[■■RENINRuns r[[[[ go M1
RE: Claim By: Reserved for Clerk's filing stamp
RECEIVED
Against the County of Contra Costa or . )
MAR ®Q 2008
District) CLERK BOARD OF SUPER IS
(Fill in the name) ) CONTRA COSTA CO.
The undersigned claimant hereby n-akes claim against the County of Contra Costa or the above-named
district in the sum of$ and .n 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 and county)
c &14
3. How did the damage or injury occur? (Give full details;use extra paper if required)
4. What particular act or omission on.6e. 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?
6. IWn�_t damage or injuries do your claim resulted? (Give full extent of injuries or damages
claimed. Attach two estimates for auto damage.)
7. Hove= was the amount claimed above computed? (Include the estimated amount of any
prospective injury or damage.)
8. Names and addresses of witnesses, doctors, and hospitals:
9. List the expenditures you made on account of this accident or injury:
DATE TIME AMOUNT
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.Gov. Code Sec. 910.2 provides"The claim shall be
signed by the claimant or by some person on his
behalf."
SEND NOTICES TO: (Attornev) 1
Name and address of Attorney
} (Claimant's Signature)
(Address)
Telephone No. ) Telephone No.
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PUBLIC RECORDS NOTICE:
Please be advised that this claim form, or any claim filed with the County under the Tort Claims Act, is subject to
public disclosure under the California Public Records Act. (Gov. Code, §§ 6500 et seq.) Furthermore, any
attachments, addendums, or supplements attached to the claim fonn, including medical records, are also subject to
public disclosure.
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NOTICE:
Section 72 of the Penal Code provides:
Every person who, with intent to defraud, presents for allowance or for payment to any state board or officer, or
to any 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
($10,000), or by both such imprisonment and fine.
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FAX (5 i0) 4 :!i-_l '_-;� LL RR
BAR #AG21732. LISCL=F�l i1:1510Ad�Ir?:369U A
" �"' '� MIKE WEINSTEIN 940 ` "16 Y 01%'10/08 j F!OC'S268495
APPLY ....7,0391 BLUE/• 80148
TIMOTHY W HONEA
2945 SHORT STj
'
OAKLAND, CA 94619-1158 08/HONDA'/FIT/SW 5D1.5SPT 5SPAUT 09/01'/07. "''`' 5
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SERVICE FUIi�01n;. 911�
HONDA .OF OAKLANDTOTAL LABOR..... 119.95
327..34TH'ST: TOTAL PARTS::.. 500.82 FIr ,I)U i1:rATi
OAKLAND: CA 94611.`. TOTAL SUBLET..:. 0.00 sr_I�%•ncr_ADVISOR'?
TOTAL G.O.G.:.., 0.00
PERFORMED.BY ./. TOTAL MISC, CHG. 3'.25 •" 'A(1=111= 'OU AL,i.r_: TO rv1AI:'1=
C DISC0.00
o.hi'OIr.1Tr`�ir_r•rr i=or, rFIE _HVIE YOU
TO / TOTAL TAX...... 143.83 RE:c;,riEsrFr)?
WHEN YOU ('AMF IN WERE 'YOLI
TIME / TOTAL'INVOICE,.$ 667.85 kNAIi ED Or,,, PriOMPTI_i';?
REPAIRSEXPLAINED Y / N (1).',f,'AS J 11r' LEI Ir f 1i c.:l rlr,;if to `
COMPLETE THE WORK III_ASONAPLE^
NOW YOU CAN MAKE''YOUR.NEXT SERVICE APPOINTMENT ONLINE! JUST
VISIT:US AT WWW.HONDAOAKLAND.COM AND CLICK ON THE (5) WAS TI IF CAF; .REAW? W1Ir r•1
PARTS/SERVICE .BUTTON TO.MAKE YOUR APPOINTMENT. y PHOMlsr_r,?
(ii WERE 7FIF SCRVICE PEHSOrdI1EL I
HELPFUL AND GOURTEOUS'.
CUSTOMER SIGNATURE -C>'nlu ivE cOMPLr_TE IFIE VV < Tcl'!
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CUSTOMER COPY [ END OF INVOICE.!05:05pm
LA t#XRZA, a-FL84 All L/ ALP
la®ATDA
MIN IM®f FNI Pse affro orlpff 4wap
327 34TH ST. o OAKLAND, CA 94609
(510) 420-9200
FAX (510) 420-9217
CELL: 510-388-0523
BAR # AG21732 US EPA ID# CAD 983620998
CUiT()M--R NO 1:09708 � MIKE WEINSTEIN ����,,�,`+��16 Y� :�, ����$— ''HDC�049
TIMOTHY W HONEA ��L'Y---- I'�� --�,039 ®LLVi 8�F148
'2945 SHORT ST ---- -..i..-- — ... . --- ---- -- - --. _ .... --- _
OAKLAND, CA 94619-1158 !'081AdWD_W1.FIT/SW 5D1.5SPT SSPAUT X09%x1707 �:,,+•" '-' S
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. 20:00
CUSTOMER.REQUEST..ft0LACEMENT.OF ONE.TIRE
AND RIM. RIM:ORDERED WITH DALE 1N PARTS 1/9/07.. JQ How WERE you TREATED BY YOUR
CAR HIT IN RIGHT FRONT NEW.RIM IN.FRONT
REPLACE ONE RIM AND TIRE .SERVICE ADVISOR?
PUT ON:RIGHT REAR QQ MERE..YOU'AB T6:MAKE: YOUR
APPOINTMENT FOR THE:TIME.YOU
PARTS--:----QTY---FP-NUMBER - DESCRIPTION----- UNIT..PRICE REQUESTED?...
JOB #:1. . 1• :: 8643058 DISK 15X•42700-SLN 385.87 .` 385.87. Q WHEN.YOU. GAME .IN WERE::YOU
JOB # 1 1 .265-024-555 195/55R15 NLOP-SP31 114.95. 114.95WAITED ON PROMPTLY?:
JOB #. ..1 TOTAL PARTS : 500.82. -
n WAS THE .LENGTH OF TIME TO
TOTAL LABOR & PARTS' 520.82 . .. COMPLETE THE WORK REASONABLE?
0.2:.32HOZ-4ALIGN :4-.WHEEL ALIGNMENT:. .::.: TEGH(S).:.688: .:.:99.95 (D WAS:. THE AR: :READY .WHEN
PERFORM.4 WHEEL:ALIGNMENT.AND PROVIDE DATA.PRINT OUT. PROMISED? :. 1
OF. SPECIFICATIONS AND.SETTINGS.
SERVICE.DUE BY TIME, .MILEAGE OR UNEVEN TIRE WEAR: O WERE.;-THE SERVICE .PERSONNEL
REAR ALIGHNMENT..OUT. SUGGEST BODY SHOP:
HELPFUL
AND FOIIRTEOI.JS^'
PERFORMED FRONT AND REAR.WHEEL.ALIGNMENT.: 07 DID wCoFIETE..rHE WORK TO
YOUR ADJUSTED TO. WITHIN FACTORY SPECI.FICATIONS...` E nn
.. u E COMALTION?
CENTERED STEERING'WHEEL. .
WAS THEW RK DONE RIGHT THE
PARTS--.-:.- QTY---.FP-NUMBER-.--- -----= DESCRIPTION. .-=---=-------------UNIT PRICE FIRST TIME'?��.�
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,,. .. . .JOB #. '2 TOTAL PARTS.- 0.00. �e ;.
�9 WOULD COMMEND
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JO.B:# 2 TOTAL:LABOR & PARTS:' 99:95 OUR:LSERVICE' DEPARTMENT r
=•• :. FRIEND?
MISC-- CODE---- DESCRIPTION--- ---=-: CONTROL.NO--:- •-
JOB I I TO TIRE DISPOSAL FEE
JOB # 1..75:. .
.;1: CA . TIRE.RECYCLE FEE
TOTAL- MISC 3.25'
ESTIMATE,-.::.-
CUSTOMER..HEREBY ACKNOWLEDGES.RECEIVING
ORIGINAL:ESTIMATE OF. 1650..00 (+
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PAGE! OF 2
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CI �i
CLAIM
BOARD OF SUi'ERViSORS OF CONTRA COSTA COUNTY
BOARD ACTION:
Claim Against the County, or.District Governed Uy )
the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT '
and Board Action. All Section references ai•e.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
1lL� Supervisors. (Paragraph IV below),
MAR; 1 2 200.8 given Pursuant to Government Code
AMOUNT: (,�t1�((�p�(�h COUNTY coUNSEL Section 913 and 915.4. Please note all
MARTINEZ CALIF. "Warnings".
CLAIMANT: ir_�rnOrb '
ATTORNEYdaE'1'l* 6, DATE RECEIVED: J�
ADDRESS:3aMA I)MV& N1i d r _**-Y DELIVERY TO CLERK ON: � GU
atW, CA q`�[ BY MAIL POSTMARKED: _-3
'�(�—D0
FROM: Clerk of the Board of Supervisors T0: County Counsel
Attached is a copy of the above-noted claim.
JOHN CUL EM , lerk, ,
Dated: (2- 2'(.�� By: Deput �L�
I.I. FROM.: County Counsel TO: Clerk of the Board of Supervisors
(This claim complies substantially with Sections 910 and 910.2.
( ) This Claim FAILS to comply substantially with Sections 910 and 910.2, and we are so
notifying claimant. The Board cannot act for 15 days (Section 910.8).
( ) Claim is not.timely filed. The Clerk should return claim on ground that it was filed late and
send warning of claimant's right to apply for leave to present a late claim (Section 911.3).
( ) Other:
Dated: i3—OP By: puty County Counsel
III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator(2)
( ) Claim was returned as untimely with notice to claimant (Section 911.3).
IV. BOARD ORDER: By unanimous vote of the Supervisors present:
This Claim is rejected in full.
Other:
I certify that this is a true and correct copy of the Board's Order entered in its minutes foi-
this date.
i
Dated: O JOHN CULLEN, CLERK, yD=De��py Clerk
WARNi.NG ( ov. 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 wide this matter. Ifyou 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 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 Martinez, ;California, postage fully prepaid a certified copy of this
Board Order and Notice to Clairrraht, addressed to the claimant as shown above.
Dated: O JOHN CULLEN, CLERK By uty Clerk
I ,
CLAIM
BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY
I l`
BOARD ACTION:
Claim Against the County, or District Governed by )
the Board of Supervisors, Routing. Endorsements, ) NOTICE TO CLAIMANT
and Board Action. All Section refrences 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
Section 913 and 915.4. Please note all
AMOUNT. odi1mWo, I "Warnings".
CLAIMANT: t_f_-( ncy-b
ATTORNEydekO 5 I t lr�)��k�'!�lu � DATE RECEIVED:
i
ADDRESS:oacoA banV 14' V2l r �BY DELIVERY TO CLERK ON: NO-)
a0mi 0'A q�)7 BY MAIL POSTMARKED:
FROM: Clerk.of the Board of Supervisors TO: County Counsel
Attached is a copy of the above-noted claim.
JOHN CUL E Ierk-
Dated: (�, ,2 2cy)� I By: Deput l,�(Q' w " ^��
II. FROM:. County Counsel TO: Clerk of the Board of Supervisors
I
(. ) 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 oil ground that it was filed late and
send warming of claimant.'s right to apply for leave to present a late claim.(Section 911.3).
( ) Other:
!
i
I
Dated: j By: Deputy County Counsel
I
III. FROM.: Clerk of the Board T0: County Counsel (1) County Administrator(2)
( ) Claim was returned as untimely with notice to claimant (Section 91 l.3).
IV. BOARD ORDER: By unanimousI vote of the Supervisors present:
( ) This Claim is rejected in full.
( ) Other:
I
I '
I certify that this is a true and correct copy of the Board's Order entered in its minutes for
this date.
Dated: JOHN CULLEN, CLERK, By Deputy Clerk
WARNING (Gov. code section 913)
Subject to cer win exceptions,you have only six(6) months from the date this notice was personally served.
or deposited in the mail to file a court acti'lon 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 Claiuian�t, addressed to the claimant as shown above.
I
Dated: JOHNICULLEN, CLERK By Deputy Clerk
I
I
!
I
EE r
LAW OFFICES OF MAR 1 2 2008
JAMES B. WICKERSHAM L I
3200A DANVILLE BLVD.,SUITE 202 CLERy<Bp;i-; C,= !_! ::3 RS
POST OFFICE BOX 1058 C01-1TRA 00:;",A CO.
ALAMO,CALIFORNIA 94507
TELEPHONE(925)831-1325
FAX (925)831-8554
March 10, 2008
SENT CERTIFIED MAIL, RETURN RECEIPT REQUESTED
County of Contra Costa
Clerk of the Board of Supervisors
Room 106, County Administration Building
651 Pine Street
Martinez, CA 94553
Re: Notice of Claim Against County of Contra Costa, California
Claimant: Eleonore Barkasy
Date of Incident: January 28,2008
Dear Sir:
Enclosed is a Notice of Claim against the City of Martinez filed on behalf of
Eleonore Barkasy.
Please direct all future communications intended for Ms. Barkasy to this office.
Thank you for your attention to this matter.
Very truly yours,
James B. Wickersham
JBW:ws
Enclosure
cc: Eleonore Barkasy
02!12.2008 . 15:45 CONTRA COSTA COUNTY CLERK OF THE 4 98518554 NO. 104 D01
BOARD OF SUPER`rISORS OF CONTRA COSTA COTU
INSTRUCTIONS TO CLAIMANT
A. A claim relating to a cause of actionfor death or for injury to person or to personal property or
growing crops shall be presented not later than six mamtas after the accrual of the cause of
actiom A claim relating to any other cause of action shall be presented not later than one year
after the acenud of th.e cause of action.
(Gov. Code§ 911.2.)
B. Claims must be fled with the Clerk of the Board of Supervisors at its office in Room 146,
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 eacb.
public entity.
B. Fraud. Seo penalty for fraudulent claims,Penal Cade Sec.72 at The end of this form.
. ■■■r■r■■■..r.■..■.■.■■.■.■■o■ ■■.■■........*r0ha0 .r9r..1
RB: Claim By: Reserved for Clerk's filing stamp
Eleonore Barkasy }
RECEIVED
Against the County of Contra Costa or ) MAR 1 2 2888
DisT riot) CLERK BOARD OF SUPERVISORS
(Fill in the name) } CONTRA COSTA CO.
l
The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named
disuiot in the sum of$ anal in support of this claim represents as follows:
n smite Jurisdiction - Superior Court
1. When did the damage or injury occur? (Give exact date and hour) i
1-28-08 , approximately ; 8 : 00 a...m.
2. Where did the damage or injury occur? (Include city and county)
Northwest corner of Heather Farms Park, Walnut Creek, CA. on
bridge xross canal. ! i
I
3. How did the damage or injury occur? (Give full details; use extra paper if required)
Claimant slipped and fell on ice that had been allowed to
accumulate on bridge.
4. What particular act or omission on the part of county or district officers; servants, or employees j
caused the injury or damage? , 1
See attached.
I!
5 What are the names of county or district officers,servants,or employees causing the
damage or injury?
Unknown. j
i
02/12/2008 15:45 CONTRA COSTA COUNTY CLERK OF THE 4 98318554 NO.104 P02
i
6. What damage or injuries do your claim resulted? (Give full extent of injuries or damages
claimed. Attach two estimates for auto damage.)
Fractured pelvis .
7. How was the amount claimed above conzpu,ted? (Include the estimated amount of any
prospective injury or damage.)
N/A
Witnesses:
8. Names and addresses ofwitae$308,doctors,andboSpitab: Barbara Rowles 925-676-3430
John Muir Hospital - Walnut Creek Angie 925-947-3703
Manorcare Convaldscent Home - Ro.ssmoor Parkway, Walnut Creek
9. List the expenditures you made on account of this accident or injury:
DATE TIAL AMOUNT
Additional witnesses:
N/A John Franklin, City of Walnut Creek
�Stan Carrtze7n�, believed to be with
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Additional Witnesses : See attached
) Gov. Code See. 910.2 provides"The claim shall be List.
) signed by the clairaw or by same person on his
)behalf."
SEND NOTICES 70: (Attorney) )
Name and address of Attorney ) yy��
James B. Wickersham, Esq.) 1�w)A&, .R
3200A Danville Boulevard,) (Claimant's Signature)
Suite 202 )
Alamo, CA 94507 ) 594 La Corso Drive
— (Address)
) I !
Walnut Creek, CA 94598
Telephone No. 925-831-1325 )Telephone No. 925-705-2018
i
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PUBLIC RECORDS NOTICE:
Please be advised that this claim form, or any claim filed with the County under the Tort Claims Act,is subject W
public disclosure under the California Public Records Act, (Gov. Code, 55 6500.et seg.) Furthermore, any
attacbments,addendums, or supplements attached to the claim form, including medical records,are also subject to
public disclosure.
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NOTICE:
Section 72 of the Peron Code provides;
Every person who,with intent to defraud,presents:for allowance or for payment to any state board or officer,or �
. i
to any county, city, or district board. or officer, authorind to allow or pay tis same if genuine, any Me 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 dollors ($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),ar by both such imprisonment and fine.
Notice of Claim Against County of Contra Costa, California
Claimant: Eleonore Barkasy
Date.of Incident: January 28, 2008
WITNESSES (con't.)
5. Antbony Oshinowo
135 Los Cerros Avenue
Walnut Creek, CA
(510) 207-1532.
6. Steven Roberts
(925) 932-33276
7. Denise Barkasy
1430 Tampico Place
Walnut Creek, CA 94598
(925) 936-8706
i
Eleonore Barkasy
D/A 1-28-08
Location: Bridge at Northwest corner of Heather Farms Park
Basis for Claim
Attached hereto is a copy of a photograph adjacent to the bridge in question which
depicts the fact that the Contra Costa Canal Regional Trial is operated by E.B.R.P.D.
which is assumed to be East Bay Regional Park District in agreement with Contra Costa
Water District, County of Contra Costa, City of Walnut Creek, City of Pleasant Hill and
City of Concord.
The Notice of Claim is being:
sent to all governmental agencies listed on the sign
near the entrance to the bridge where claimant fell.
Claimant is uncertain as to the exact oversight role and ownership role paid by
each of the governmental agencies.
It is claimant's contention that the bridge in question was improperly designed
and maintained and that the governmental agencies involved had knowledge that ice
would accumulate on a wooden type;of walkway during winter months. Said agencies
failed to place any form of warning signs on the bridge. Claimant entered the bridge
without knowledge of the icy conditions, did not see the ice prior to fall and slipped and
fell as a result of defective and/or maintenance or other negligence on the part of the
owners and operators and overseers of the subject bridge.
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. I CL;AiIVI
BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY
I
BOARD ACTION:
Claim Against the County, or. District Governed by )
the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT
and Board Action. All Section references ai•e.to ) The copy of this document mailed to
California Government Codes.. I ) you is your notice of the action taken
on your claim by the Board of
I
Supervisors. (Paragraph IV below),
MAR 13 2008 given Pursuant to Government Code
AMOUNT: 3Z��'G3 COUNTY COUNSEL Section 913 and 915.4. Please note all
MARTINEZCALIF. "Warnings".
�I I
CLAIMANT: M I1 Ude LI Ji'1
I
ATTORNEY: KP.r(,I;tJ n9troa,, rDATE RECEIVED: 2tD
I
ADDRESS: RD, 13r)l BY DELIVERY TO CLERK ON:
BY MAIL POSTMARKED: 12 �g
FROM: Clerk of the Board of Supervisors T0: County Counsel
Attached is a copy of the above-noted claim.
JOHN CU N, Clerk/
Dated: hwA l3 �_bn I
I By: Deput
iI. FROM.: County Counsel TO: Clerk of the Board of upervisors
i
(: This claim complies substantially with Sections 910 and 910.2.
I
( } 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).
i
( ) 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).
(KOther:
I^e5 0C>-?5;b k, --� po+IhI t✓Las 1,Y) +I V_ Ct +L1 o SC
F-rm -l S c o
1
Dated: By: aq� eputy County Counsel
I
ili. .FROM: Clerk of the Board TO: County Counsel (1) County Administrator(2)
( ) Claim was returned as untimely:1with notice to claimant (Section 911.3).
i
1V. BOARD ORDER: By unanimous vote of the Supervisors present:
This Claim is rejected in full. 1
'( ) Other:
I
i
I certify that this is a true and correct copy of the Board's Order entered in its minutes for-
this date.
I
Dated: JOHN CULLEN, CLERK, By D uty Clerk
WARNING ( ov. code section 913) 1
Subject to certain exceptions,you have only six(6) months from the dat his notice was personally served
or deposited in the mail to file a court action on this claim.See Governinent Code Section 945.6.You may
seek the advice of an attomey of your choice in connection with this matter. If you want to consult all
attorney,you should do so immediately: *For Additional Warniilg See Reverse Side ofTliis 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 1 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.
I
Dated: rtbaxo JOHN CULLEN, CLERK By r Deputy Clerk
I
I
I
i
CLAIM (✓ `
BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY
BOARD ACTION:
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
-
Vj 3 i Section 913 and 915.4. Please note all
AMOUNT: . Jry r
"Warnings".
CLAIMANT: M I'1 U�e.LL x'n
ATTORNEY: f4ar atf2 r-VISt.l`a (DATE RECEIVED: `l-1GUZGh � � ZCZ'�
ADDRESS: 13()X C-1C ( BY DELIVERY TO CLERK ON:
CIA" BY MAIL POSTMARKED:
FROM: Clerk of the Board of Supervisors T0: County Counsel
Attached is a copy of the above-noted claim.
JOHN CU N, Cleric'
Dated: ��'��� By: Derut CUM
she-� ctit Zb�
i.I.. FROM.: County Counsel TO: Clerk of the Board of.. upervisors
( ) This claim complies substantially with Sections 910 and 910.2.
( ) This Claim FAILS to cornplyi substantially with Sections 910 and 910.2, and we are so
notifying claimant. The Board cannot act for 15 days (Section 910.8),
I
( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and
send warning of claimant's right to apply for leave to present a late claim (Section 911.3).
( ) Other.
Dated: By: Deputy County Counsel
III.. FROM:: Clerk of the Board ATO: County Counsel (1) County Administrator (2)
( ) Claim was returned as untimely with notice to claimant (Section 911.3).
IV. BOARD ORDER: By unanimous vote of the Supervisors present:
( ) This Claim is rejected in full.
( ) Other:
I certify that this is a true and correct copy of the Board's Order entered in its minutes for
this date.
Dated: JOHN CULLEN, CLERK, By Deputy Clerk
WARNING (Gov. code section 913)
Subject to certain exceptions,you have only six(6) months from the date this notice was personally served
or deposited in the mail to file a court action on this claim.See Government Code Section 945.6.You may
seek theadvice 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 ofThis Notice.
AFFIDAVIT OF MAILING
I declare under penalty of perjury that i am now, and at all times herein mentioned, have
been a citizen of the United States, over age 18; and that today I deposited in tine 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.
r
Dated: JOHN'CULLEN, CLERK By Deputy Clerk
0062-025310
I
! P. O. BOX 997195
MERCURY SACRAMENTO CA 95899
INSURANCE COMPANY
A member of Mercury Insurance Group !
03/12/2008 RECEIVE®
MAR 1 3 2008
Mailed to:
CONTA COSTA BOARD OF SUPERVISORS CLERK BOARD OF gijP F,V•ISORS
651 PINE STREET ROOM 106 CONTRA COSTA Cp.
MARTINEZ CA 94553 l
I
I
I
ATTENTION:, CLERK OF THE BOARD OF SUPERVISORS
OUR INSURED) MITCHELL LISON
OUR FILE NO:! 2008 0015 000775-86
DATE OF.LOSS:I 02/05/2008
YOURINSURED
YOUR FILE NUMBER:
I
Dear CONTA COSTA BOARD OF SUPERVISORS
We have obtained information regarding the above date of loss suggesting that damages incurred were caused
by your insured's negligence.
Enclosed for your review please find copies of our supporting documentation. The breakdown of our payments
is as follows:
Initial Repairs 2354.22
Deductible 500.00
Supplements 136.40
Rental Expense 0.00
Out of Pocket Expense 35.81
Other
Salvage +
VLF, if applicable
Total 3026.43
Total Amount Due i 3026.43
Our insured's version of the loss is as follows:
Our insured was traveling on road and hit veli y large pothole causing damage to her vehicle.
Please return a copy of this form with your payment, to ensure proper credit.
Should you have any questions or need '!additional information, please contact me. Thank you for your
cooperation. !
Sincerely,
I
Shaun Raedel !
(9161636-1534 Ext 2239
Enclosures
I
I
C21 05/2007
I
. . _4 EOARA of STJ OF CONTRA COS'T'A COUNTY
s
INSTRUCTIONS TO CLAMANNI
A, �A claim relating to a cause of action for death or for injury to person or to personal property or
grovwino crops shall be presented not later than six months after the accroal of the cause of
action.. A claim relating to any other cause of action shall be Presented not lager than one year
air the accrual of the cause of action.
(Gov, Code§ 911.1) j
$, Claims must be filed with the Clerk of the Board of Supen►isors at its office in Room 1.06,
Counts-Administration Building, '651 Pine Street,?vlatinez,CA 94553.
i
C. Td:claim is against a district governed by the Board of Supervisors, rather than the County, the
name of the District should be filled in.
p. If the claim is against more than:one public entity, separate,claims mint be filed against each.
public entity.
E. Fraud. See p�alty for_frauduleut.claims,-Penal Code-Sec.i2 of-the end of this form.:-- —
-- -
a a a kNWAXa UNamR■Rag a-f Mins l l R o sings kXWz 6 am Ran It Isms[iaIt mRq It B O lire■O its Arm Arm a S Q it KI
RE: Claim By: Reserved for Clerk's filing stamp
ECEI E
Against the County of Contra. Costa or )
MAR 1 3 -2008 - -
District) CLERK BOARD OF SUPERVISORS
(Fill in the name) )' COi•j T FiA COSTA CO.
The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named
district in the sum.of$ and!in support of this claim represents as follows:
r
1. When did the damage or injury occur? (Give exact date and hour)
(. 10 p m als-�o g
2. Where did the damage or injury occur? (Include city and county)
dShQnec SV __J�JVof.. I So, �iRckvnCtSC0,
3. How did the damage or injury occur? ((Hve full details;use extra paper if required)
-LnsuQt3& wr.s cl2ivti1 Gown O' �hanessy IWO * k�-- o- pothole, aftv
-PLJJocQ UJe f 0.Y1� n 0-rk 'e S ,oThec e-o.r s cA.I so had f(cL+ "hies
4. What'pardc:ulas act or omission on the part of county or district officers, servants, or employees
caused the injury ordamage? i
__pp "�5�
��l 1�a�v�t vle�resL
What are the names of county or district officers, servants, or employees causing the
damage or injury?
Ulm k
Z d Lei 'ONS 1N3''.D NH!N YISH k)3 VE!dt8 8002 '0! ' HSN
6. Wat damage or injuries do your claim. resulted? (Give full extent of injuries or damages
claimed Attach two estimates for auto damage,)
rtlR� Ej geunepns;iov
7. How was the amount claimed `,above computed? (Include the estimated amount of any
prospective injury or damage.)
,es+ , 'p"(TuCies COPWS Of 1(3ss QJCS ir)e.(Lk0teC.
8. Names anal addresses of witnesses; doctors, and hospitals:
Q,v►e;Q',�9�l� So-,�.. �,�..n e,�;s e� �ee,�e� iJt sf 2y �CQ��.,� re.��0 9. List the expenditures you made on,:account of this accident or injury:
DA'Z'E T114 AMOUNT
• I �3oa(o• �f3
o VEENIX a QN&adkaq 4t;a61911 Noun Atm 9220 AnRam its■amen Pa PNaamaakin PREMNE kntasa Pu Op a p Erma Opp a 66x91
-- — --- — —)
.66V.-Code-Se-c-. 910.2 provides'The claim shall be — — --
signed by the claimant or by some person on Isis
be�If.
SEND NOTICES TO: (Attorney) )
Name anal address of Atkorrney )
ma"L ,
(Claimant's ignature)
(2, 15 Q6 13i-7 -
- ) (Address)
)
Telephone No. )T Iephone No.�9 t 1 CQ 3 6 — / S3 ,�, a3
aam9 a no ax EVEN a s a sap DLaa o x a a mamma■nan EON9119 SAN Kahn MR an a■PNaaxa■Pp Oil on ma.■aa x Ritz ox 991
pUSLIC 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. Codi, 55 6500 at seq.) Furthermore, any
attachments,addenadums, or supplements attached to the claim form, including medical records, are also subject to
public disclosure.
m aap'p at h a Nan a mun a Nh Pan UPS a a®gpamtaa xgMae t ILK Ra Its east a NapaNa aq Nam one a■a was a apt at has all
?NOTICE:
Section 72 of the Penal Code provides:
I
Every person who, with intent to defraud, presents ibr allowance or for pa)Tnent to any state board or officer, or
to any county, city, or district board or officer', authorized to allow or pay the same if gsnui*te, any false or
fraudulent claim, bill, account voucher, or writing, is punishable either by imprisonment iu the County jail for a
Period of not more thaw one year, by a$fie of not exceeding one thautand dollars ($1,000M), or by both such
imprisonment and fae, or by imprisonment in the state prison, by a fine of not =Bodiag ten thousand dollars
(S 10,000), or by both such imprisonment and fine.
0 'd 0� 'ON
1N3W3`)dNV'�'! �Si� ��� A8tiO'.? 8001 '0! '�n6N
Date: 3/10/2008 08:12 AM
Estimate ID: 080016000775-8600101
Estimate Version: 1
Supplement: 1(F) 3/10/2008 08:05:48 AM
Profile ID: CUSTOMIZED
I
NO SUPPLEMENTAL REPAIRS WILL BE AUTHORIZED FOR PAYMENT WITHOUT WRITTEN
APPROVAL PRIOR TO REPAIRS BEING PERFORMED.
I
NO SUPPLEMENTS WILL BE PAID UNLESS VEHICLE IS AT SHOP.
PLEASE CONTACT TERRY O'CONNELL REGARDING ANY SUPPLEMENT.
*******NO SUPPLEMENTS WILL BE HONORED AFTER 6 MONTHS*******
Mercury Insurance Company
P.O!Box 1008,GILROY,CA 95037
(415)308-7019
Fax: (916)636-1597
Damage Assessed By: TERRY O'CONNELL 5357 Appraised For: SHAUN RAEDEL
(800)827-1570 ext.2239
Supplemented By: TERRY O'CONNELL 5357
Condition Code: Good Type of Loss: Collision
Date of Loss: 2/6/2008
Contact Date: 2/11/2008
Deductible: 500.00
Policy No: 040105005316743 Claim Number: 080015000775-8600101
Insured: MITCHELL LISON
Owner: MITCHELL LISON
Address: 4201 INDUSTRIAL AVE,BENICIA,CA 94510
Telephone: Work Phone: (707)745-1320 Home Phone: (415)681-9035
Mitchell Service: 915529
Description: 2002 Chrysler PT Cruiser Limited Vehicle Production Date: 1/02
Body Style: 41)Wgn Drive Train: 2.41-Inj 4 Cyl 6M FWD
VIN: 3C8FY68B82T309053 License: 4VZC452 CA
Mileage: 24,538
OEM/ALT: A Search Code: SJOSE
Color: red j
Options: ALUM/ALLOY WHEELS,POWER DOOR LOCKS,CRUISE CONTROL,POWER SUNROOF
Line Entry Labor Line Item Part Type/ Dollar Labor CEG
Item Number Type Operation Description Part Number Amount Units Unit
WHEEL
S1 1 500265 BDY REMOVE/REPLACE WHEEL 2Q594.00 4656674AB 1,188.00' 0.6 0.3T
2 500271 BDY REMOVE/REPLACE WHEEL VALVE STEM 2@2.98 2073355 5.96 T
MANUAL ENTRIES
S1 3 900500 BDYADD'L LABOR OP 2 MOUNT AND BALANCE Sublet 60.00' 0.0'
FRONT SUSPENSION
4 600277 MCH ALIGN FOUR WHEEL -M 1.6 1.6
5 500279 MCH REMOVE/REPLACE BLEED ABS SYSTEM -M 0.6 0.6
S1 6 505568 MCH REMOVE/REPLACE R FRT SUSP WHEEL HUB -M 4670292AC 165.96' 1.9 # 1.9T
7 500286 BDY REMOVE/REPLACE L FRT SUSP LUG STUD 5@1.45 6606730AA 7.25 T
S1 8 505571 MCH REMOVEIREPLACE L FRT SUSP HUB BEARING -M 4668442AA 64.08' INC # 1.9T
S1 9 505579 MCH REMOVEIREPLACE L FRT SUSP STEERING KNUCKLE -M 627247SAA 363.00' 1.7 # 1.9T
FRONT DRIVE AXLE
This estimate ha I been re-calculated with a modified profile.
ESTIMATE RECALL NUMBER: 02/11/2008 11:06:26 0800150007758600101
UltraMate is�a Trademark of Mitchell International
Mitchell Data Version: FEB_08_V Copyright(C)1994-2005 Mitchell International Page 1 of 3
UltraMate Version: 6.0.028 All Rights Reserved
i
Date: 3/10/2008 08:12 AM
Estimate ID: 080016000776-8600101
Estimate Version: 1
Supplement: 1(F) 3/10/2008 08:05:48 AM
Profile ID: CUSTOMIZED
S1 10 501520 MCH REMOVE/REPLACE L DRIVE AXLE SHAFT ASSEMBLY -M 5274711AD 137.99' 0.3 # 0.3T
MANUAL ENTRIES
11 900500 BDY* REMOVE/REPLACE L/FRT TIRE COOPER TRENDSETTER "QUAL REPL PART 110.00' 0.0' T
12 p205/55r16 8/32 remaining tread
13 BETTERMENT-P UFRT TIRE COOPER TRENDSETTER%30.00 33.00 T
14 900500 BDYADD'L LABOR OP TIRE DISPOSAL FEE AND TAX Sublet 6.00' 0.0'
S1 16 900500 MCH' ADD'L LABOR OP PRESS BEARING TO DETERMINE SIZE Existing 0.5'
"-Judgment Item
#-Labor Note Applies
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Prior Damage
scrapes on frt bumper lower,scuff on rear bumper
Add'I
Labor Sublet
1. Labor Subtotals Units Rate Amount (Amount Totals II. Part Replacement Summary Amount
Body 0.6 75.00 0.00 66.00 111.00 Taxable Parts 2,042.24
Mechanical 6.6 106.00 0.00 0.00 699.60 Sales Tax @ 8.600% 173.69
Non-Taxable Labor ! 810.50 Total Replacement Parts Amount 2,215.83
Labor Summary 7.2 810.60
III. Additional Costs Amount IV. Adjustments Amount
Total Additional Costs 0.00 Betteffnent 35.81-
Insurance Deductible 500.00-
. �
Customer Responsibility 535.81-
1. Total Labor: 810.60
II. Total Replacement Parts: 2,215.83
III. Total Additional Costs: 0.00
Gross Total: 3,026.43
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IV. Total Adjustments: 535.81-
Net Total: 2,490.62
Less Original Net Total: 2,354.22
Net Supplement Amount: 136.40
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S1: TERRY O'CONNELL 5357 136.40
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Point(s)of Impact
11 Left Front Corner(P)
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Insurance Co: MERCURY INSURANCE COMPANY Inspection Site: MIRALOMA AUTO CARE
Address: PO BOX 1008 Address: 701 PORTOLA DR
GILROY,CA 95021 SAN FRANCISCO,CA
Telephone: (416)308-7019 Inspection Date: 2/11/2008
Fax Phone: (916)636-1597
This estimate has been re-calculated with a modified profile.
ESTIMATE RECALL NUMBER: 02/11/2008 11:06:26 080015000775-8600101
UltraMate is a Trademark of Mitchell International
Mitchell Data Version: FEB_08 V Copyright(C)1994-2005 Mitchell International Page 2 of 3
UltraMate Version: 6.0.028 All Rights Reserved
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Date: 3/10/2008 08:12 AM
i Estimate ID: 0800150007755600101
Estimate Version: 1
Supplement: 1(F) 3/10/2008 08:06:48 AM
Profile ID: CUSTOMIZED
Body Shop: MIRALOMA AUTO CARE
Address: 701 PORTOLA DR
SAN FRANCISCO,CA 94127
Telephone: (415)664-3746
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NOTE: THIS IS NOT AN AUTHORIZATION TO REPAIR. THE UNDERSIGNED REPAIR
FACILTIY AGREES TO REPAIR THIS VEHICLE USING INDUSTRY ACCEPTED
EQUIPMENT AND REPAIR METHODS, AND TO COMPLETE AND GUARANTEE SUCH SAFE
REPAIRS AT .A PRICE OF $ , INCLUDING ALL CHARGES INCIDENTAL
THERETO.
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THE WRITING OF THIS ESTIMATE DOES NOT CONFIRM COVERAGE OR GUARANTEE
ORIMPLY ACCEPTANCE OF LIABILITY. THIS ESTIMATE IS FOR THE REPAIR OF
DAMAGE CLAIMED BY THE OWNER OF THE VEHICLE, AND THIS ESTIMATE IS NOT
AN ADMISSION THAT THE DAMAGE RESULTED FROM THE ALLEGED LOSS. SHOPS
SHOULD FORWARD ALL SUPPLEMENTS TO TERRY O'CONNELL AT FAX ( )
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AGREED PRICE BY:
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This estimate has been re-calculated with a modified profile.
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ESTIMATE RECALL NUMBER: 02/11/2008 11:06:26 0800160007764600101
UltraMate is alTrademark of Mitchell International
Mitchell Data Version: FEB_08_V. Copyright(C)1994-2005 Mitchell International Page 3 of 3
UltraMate Version: 6.0.028 All Rights Reserved
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Date: 311012008 08:12 AM
Estimate ID: 080015000776-8600101
Estimate Version: 1
Supplement: 1(F) 3/10/2008 08:05:48 AM
Profile ID: CUSTOMIZED
Mercury' Insurance Company
P.O.Box 1008,GILROY,CA 96037
(415)308-7019
Fax: (916)636-1697
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Supplement Delta Report
Comparison of Estimate 080015000775-8600101 Supplement 0 and Supplement 1
Damage Assessed By: TERRY O'CONNELL 5357
Supplemented By: TERRY O'CONNELL 5367
Insured: MITCHELL LISON
Owner: MITCHELL LISON
Vehicle Description: 2002 Chrysler PT Cruiser Limited
Date of Loss: 2/5/2008
Line Labor Line Item Dollar Labor CEG
Item Type Operation Description Part Type Amount Units Unit
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Changed Entries
1 BDY REMOVE/REPLACE WHEEL I New 1,080.00 0.6 0.3T
S1 1 BDY REMOVEIREPLACE WHEEL New 1,188.00'< 0.6 0.3T
3 BDY ADD'L LABOR OP 2 MOUNT AND BALANCE Sublet 40.00' 0.0'
S1 3 BDY ADD'L LABOR OP 2 MOUNT AND BALANCE Sublet 60.00"< 0.0'
6 MCH REMOVEIREPLACE R FRT SUSP WHEEL HUB -M New 199.00 1.9 1.9T
S1 6 MCH REMOVEIREPLACE R FRT SUSP WHEEL HUB -M New 165.96'< 1.9 1.9T
8 MCH REMOVE/REPLACE L FRT SUSP HUB BEARING -M New 98.60 INC 1.9T
S1 8 MCH REMOVEIREPLACE L FRT SUSP HUB BEARING -M New 64.08*< INC 1.9T
9 MCH REMOVE/REPLACE L FRT SUSP STEERING KNUCKLE -M New 330.00 1.7 1.9T
S1 9 MCH REMOVE/REPLACE L FRT SUSP STEERING KNUCKLE -M New 363.00•< 1.7 1.9T
10 MCH REMOVEIREPLACE L DRIVE AXLE SHAFT ASSEMBLY -M New 153.00 0.3 0.3T
Si 10 MCH REMOVEIREPLACE L DRIVE AXLE SHAFT ASSEMBLY -M New 137.99'< 0.3 0.3T
Added Entries
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S1 15 MCH ADD'L LABOR OP PRESS BEARING TO DETERMINE SIZE Existing 0.6`
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Global Changes
No Deductible,Customer Responsibility,Labor Riate,or Part Adjustment changes were made.
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Estimate profile calculation settings(other than labor rates and adjustments)have changed.
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Amount
Original Estimate: 2,354.22
Supplement 1 136.40
Orig Total Tax 168.62
Supp 1 Total Tax 173.69
Net Supplement Amount 136.40
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Net Total 2,490.62
Program Calc Versions Data Versions
Supp 0 6.0.028 JAN 08 V
Supp 1 6.0.028 FEB 08 V
ESTIMATE RECALL NUMBER: 2/11/2008 11:06:26 080015000775-8600101
UltraMate is a Trademark of Mitchell International
UltraMate Version: 6.0.028 Copyright(C)1994-2006 Mitchell International. Page 1 of 1
All Rights Reserved
II
Claim# 080015000775-8600101 Owner: LISON,MITCHELL Page 1 of 9
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https://www.emitchell.com/review/REVMOD7PRINTIMAGES.asp?PrintXMLPID=2160... '3/12/2008
Claim # 080015000775-8600101 Owner: LISON,MITCHELL. Page 5 of 9
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Claim# 080015000775-8600101 Owner: LIISON,MITCHELL Page 6 of 9
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Mercury Insurance :: NextGen Page 1 of 1
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Loss Check Maintenance SRAEDEL
M ERC V RY 1 NextGen 05 03/12/2008
INSURANCE GP0UP
Claims I VIIP I LT I Log Off
AClaimsm JInquiry:L
Claim Log I Adjust Claim I Maintenance I Directories I Alert
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Check Li heck Details®
Diary Maintenance
Claim Number 1 2008 0015 000775-86 Handling Unit 0062 CAPITOL CLAIMS UNIT
File Notes
Claimant Maintenance Policy Number j 0401 05 005316743 Date of Loss 02/05/2008 09:30 PM
Check Maintenance Named Insured MITCHELL LISON Claim Status Regular Open
Request Vendor Maint 025310 Shaun Raedel (916)
Adjuster 636-1534 Ext 2239 Orig.Cost of Vehicle 10,000.00
Subrogation Referral
Subrogation Report Loss Check Issued Maintenance
Assign Subro Vendor
Check Maintena Ice Type* iii Payee Type Reportable
Check Number Control
Clmt Pymt Record 460514048 I Code Vendor Code 61049053
Legal File Assignmt
Payee MIRALOMA AUTO CARE
Closing Suit
Additional
BI/UM Settlmnt Eval. Payee AND LAURA LISON
Veh. Registration Address 701 PORTOLA DR,SAN FRANCISCO,CA 94127
Issued By 02,5310 Shaun Raedel Issue Date 02/20/2008
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Coverage Amount Type Adjuster Code Total Loss
COLL 2,354.22 Partial 022272 N
Check Amount 2,354.22 In Full Settlement..Of CN Claims
Backup Withholding. 00.00 To Be Authorized By Eric Beitzel
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Net Check Payee 2,354.22 Authorized By Eric Beitzel
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Claimant/Reference LAURA LISON Authorized Date 02/21/2008
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Comment ! 2002 CHRYSLER PT
' ��:�SUhmit ' ' Clearrtrfi.�.� {�Exik
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https://nextgen.mercuryinsurance.com/Claims wet)/checkMaintenanceDir.do 3/12/2008
Mercury Insurance ::NextGen Page 1 of 1
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MERCUaY LOSS Check Maintenance SRAEDEL
03/12/2008
INSURANCE GROUP NextGen 05
Claims I WIP 11T I Log Off
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Claim sm JInqui YLA,
Claim Log I Adjust Claim I Maintenance I Directories I Alert
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%ALj Check List�Check Details
Diary Maintenance
Claim Number 2008 0015 000775-86 Handling Unit 0062 CAPITOL CLAIMS UNIT
File Notes
Claimant Maintenance Policy Number 040105 005316743 Date of Loss 02/05/2008 09:30 PM
Check Maintenance Named Insured MITCHELL LISON Claim Status Regular Open
Request Vendor Maint Adjuster 025310 Shaun Raedel (916) Orig.Cost of Vehicle 10,000.00
Subrogation Referral 636-1534 Ext 2239
Loss Check Issued Maintenance
Subrogation Report
Check Maintenance Type' �!� Payee Reportable
Assign Subro Vendor Type
Control Vendor
Clmt Pymt Record Check Number 1 Code Code 61049053
Legal File Assignmt Payee IMIRALOMA AUTO CARE
Closing Suit
Additional
BI/UM Settlmnt Eval. Payee I
Veh. Registration Address 1701 PORTOLA DR,SAN FRANCISCO,CA 94127
Issued By 025310 Shaun Issue
Raedel Date 03/12/2008
Requested
to Print 03/12/2008
Date
Coverage Amount Type Adjuster Code Total Loss
COLL 136.40 Final 025310 N
Check Amount136.40 In Full Settlement Of CN Claims
Backup Withholding 00.00 To Be Authorized By Eric Beitzel
Net Check Payei 136.40 Authorized By
Claimant/Reference LAURA LISON Authorized Date
Comment 2002 CHRYSLER PT CRUISER LAURA LISON
(„ori5ubmit �r�.rrrrr�[lear� (.rrri�irrirExit
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https://nextgen.mercuryinsurance.com/ClaimsWeb/checkMaintenanceDir.do 3/12/2008
VC:jn;ea
Tliu Feb. 28 ]0 : 07 :;14 2008
'r EVENT H:r' )RY DETAIL: S080364060
ibar n 02-28-b 1
Si _FRAO, CISCO POLICE 10 : 0'7
bSWORTH) 142
21 : 01i32 CT14; ENTRY RP:PAb.,.3,r-RZYER\TX:LARGE/I)EEP -POT HOLE JUST SOUTH OF
0SHAUGHNESSY. —DPW NOTIF?B
:21 : 0I : 32 CT14 PRIOR 386 02/03/08 52941 (13 MOREY
121 - 03 -. 02 DPO6 BRDCAST 080364066 1 586 CS14AUGHNESSY BL/BOSwoRTH ST' Sv 10-8 :
I 2RO314 3H4D 311-15C 3H39 3X90C 3H107 3H108 3HI13
121 : 03 :05 DPO6 DISP-ENR 2 R D 314:UN
.2l. :'24 : 38 DPO6 PREEMPT 2RO3H
21 : 24i42 DPO6 DISP-ENR 3H:?
1 21 : 24 :45 OPOG CLEAR 3H HM
21 : 24 : 45 DP06 CLOSE
tall Recap:
1ZNITIATE,. 20:59: 20 02/05/06 (CALL NUMBER: #4060 1
S' XTRY- 21:01:32 iCURRENT STATUS: CLOSED
EISPATCH: 21 : 03 : 05 IPRIMARY UNIT: 3H
N SCENE: ',JURISDICTION: SP
(CLOSE: 21:24 :45 DISPOSITION: RAN
i ,DDRES.9 ; C)SHATIGHNESSY .BL/130SWOR-TH. _S7,SF .-(:D=3H--9-99 0SHAUGHNESSY 1-13 0 0--BOSWORTH)
WsA- —3H
SECTOR: H2 TYPE: 586 *HAZARD
807 'PRIORITY: I
(FIRE: 8179 PRIOR HISTORY
!OPERATOR ASSIGNMENTS : CT14 A09543
DPCG A08275
SHAUN RAEDEL'
Page
MAR 0 3 2008
CLAIMS
'3N1 33�J00 V3dV XVS d90,.Z6 9C)
00 jp-iq
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CLAIM
BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY
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BOARD ACTION:—c A
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
I
on your claim by the Board of
i Supervisors. (Paragraph IV below),
RN619.a�E iven Pursuant to Government Code
+�►�; Rection 913 and 915.4. Please note all
AMOUNT: 6'0/ 000.d D � MAR 212008 "Warnings".
COUNTY S_QwL 7e e MRINEZCUR .
ATTORNEY: DATE RECEIVED: %War00�
ADDRESS: 2oo7o0914,413Y DELIVERY TO CLERK ON: —, _
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CIA- l�553. BY MAIL POSTMARKED:
FROM: Clerk of the Board of Supervisors TO: County Counsel
Attached is a copy of the above-noted claim.
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JOHN CULLEN, Clerk
Dated: �/ By: Deputy
II. FROM: County Counsel TO: Clerk of the Board of Supervisors
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(This claim complies substantially with Sections 910 and 910.2.
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( ) 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).
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( ) Claim isnot timely filed. The Clerk should return claim on ground that it was filed late and
send warning of claimant's right toapply for leave to present a late claim (Section 911.3).
( ) Otlier:
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Dated: �"a7— I By: Deputy County Counsel
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111. FROM:: Clerk of the Board T0: County Counsel (1) County Administrator(2)
( ) Claim was returned as untimely with notice to claimant (Section 911.3).
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1V. BOARD ORDER: By unanimous vote of the Supervisors present:
(x( This Claim is rejected in full.
( ) Other:
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I certify that this is a true and correct copy of the Board's Order entered in its minutes for
this date.
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Dated: o JOHN CULLEN, CLERK, By Depu elk
WARNI.N (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 niail 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 widr this matter. 'lf'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 per juryjthat i am now, and at all times herein mentioned, have
been a citizen of the United Statesi, 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 claim r a shown above.
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Dated:Cj,CA (o
5? JOHN CULLEN, CLERK B leek
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C LA.1 iv1 t
BOARD OF SUPERV.I.SO.RS OF CONTRA COSTA COUNTY
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BOARD ACTION: April!15', 2008
Claim Against the County, of District Gouierned 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
!!!!llll
MAR on your claim by the Board of
212008
Supervisors. (Paragraph IV below),
jcouNTY coUNSEL given Pursuant to Government Code
I MARTiNFZCALII:. Section 913 and 915.4. Please note all
AMOUNT: TBA
I "Warnings".
CLAIMANT: Ashley Elizabeth Bocks
C/O Michael Bocks
ATTORNEY: N/A DATE RECEIVED: March 5, 2008
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ADDRESS: 1368 Elizabeth Ct. BY DELIVERY TO CLERK ON: March 5, 2008
Walnut Creek, CA 94596 N/A
BY MAIL POSTMARKED:
FROM: Clerk of the Board of Supervisors T0: County Counsel
Attached is a copy of the above-noted claim.
March 10, 2008.:, JOHN CULLEN, C /k
Dated: I By: Deputy G
11. FROM.: County Counsel TO: Clerk of the Board of Supervisors
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(Alis claim complies substantially]with Sections 910 and 910.2.
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( ) 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).
I
O Claim is not timely filed. The Clerk should return.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.911.3).
( )
Other:
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Dated: �� 2'�' ! By: Deputy County Counsel
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I11. FROM: Clerk of the Board T0: County Counsel (1) County Administrator(2)
( ) Claim was returned as untimely with notice to claimant (Section 911.3).
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1V. BOARD ORDER: By unanimous vote of the Supervisors present:
This Claim is rejected in full.
( ) Other:
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I certify that this is a true and correct copy of the Board's Order entered in its minutes for
this date.
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Dated: o JOHN CULLEN, CLER. , By uty Clerk
WARNING ( ov. code section 913)
Subject to certain exceptions,you have only six(6) months froin tie 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. ff you want to consult an
attorney,you should do so immediately. *For Additional Warning See Reverse Side ofThis Notice.
AFFIDAVIT OF MAILING
I declare under penalty of perjuiry that 1. 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 clainnan.t own above.
Dated: O ►Le O _ JOfIN CULLEN, CLERK B.y uty Clerk
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