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CITY OF EMERYVILLE
CLAIM FORM
Please Type or Print and return to:
City Attorney's Office, City of Emeryville
1333 Park Avenue Emeryville, Ca 94608
Phone: 510.596.4381 Fax: 510.596.3724
Email: [email protected]
AGAINST City of Emeryville - Public Works
(Name of Entity)
Black Bear Diner
Claimant's name
SS#
N/A
Claimant's date of birth Telephone # (650)393-5934
Clamant's address 5750 Christie Ave., Emeryville, CA 94608 Address where notices about claim are to be sent, if different from above:
7/31/2025
Date of incident/accident:
7/31/2025
Dare injuries, damages, or losses were discovered:
Location of incident/accident: 5750 Christie Ave, Emeryville, CA 94608 What did entity or employee do to cause this loss, damage, or injury? Main water line break disrupted business. (Use back of this form or separate sheet if necessary to answer this question in detail.) but are the names of the entity's emplovees who caused this injury, damage, or loss (if known)? City of Emeryville - Public Works
W her specific injuries, damages, or losses did claimant receive? We encountered huge financial loss because we had no running water. (Use back of this form or separate sheet if necessary to answer this question in decail) What amount of money is claimant seeking, or which is the appropriate court of jurisdiction (Government Code 910(C)1, $5,800.00
How was this amount ealculated (please itemize) This is based on Daily Sales and Labor.
We had to shut down causing us loss in sales. We had to pay the employees that came in and were then sent home. (Use back of this form or separate sheer if necessary to answer this question in detail) 08/04/2025
Date Signed: Signature:
If signed by representative:
Representative's Names Address
Telephone #
Relationship to Claimant: