CITY OF RIALTO CITY CLAYSTERIALTO
LIABILITY 2022 MAR 10 PM 3:01
CLAIM FOR DAMAGES
CITY RECEIVED
TO PERSON OR PROPERTY CLERK
1. Claims for death, injury to person, or to personal property must be filed not later than six (6) months after the occurrence (Gov. Code §911.2).
2. Claims for damages to real property must be filed not later than one (1) year after the occurrence (Gov. Code §911.2). RETURN TO:
3. READ ENTIRE CLAIM FOR BEFORE FILING Rialto City Clerk's Office
4. ATTACH SEPARATE SHEETS, IF NECESSARY, TO GIVE FULL DETAILS Mail: 150 S. Palm Ave., Rialto, CA 92376 Address: 290 W. Rialto Ave., Rialto, CA 92376
CLAIMANT INFORMATION:
JEAN M. HURBARD
FULL NAME DATE OF BIRTH
RIALTO, CA 92316
HOME ADDRESS INCLUDING CITY, STATE & ZIP HOME TELEPHONE NO.
BUSINESS ADDRESS INCLUDING CITY, STATE & ZIP BUSINESS TELEPHONE NO.
ADDRESS AT WHICH CLAIMANT DESIRES TO RECEIVE
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM
(if different from home address provided above):
1. WHEN DID DAMAGE OR HMURY OCUR? DATE: Oct, 17,2021 _ TIME: 7:30 0AMBPM
2. PLACE OF AGGIDENT (OCCURRENCE) BE SPECIFIC - Describe fully and (if applicable) locate on diagram on reverse side of this sheet.
Where appropriate, give street names and addresses, measurements and landmarks.
Ai ABOVE ADDRESS SEE ATTACHED PHOTO OF PROPERTY
AND INVOICE SHOWING ACCOUNT PAID
3. HOW DID DAMAGE OR INJURY OCCUR?
THE ROOTS OF A CHINESE ELM TREE LOCATED NEAR THE CURB
CLOGGED THE MAIN SEWER LINE CADSING BLACK WATER
TO BACK UP INTO TWO BATH TUBS. SEE ATTACHED INVOICE.
4. WERE POLICE AT THE SCENE? • YES IS NO WERE PARAMEDICS AT THE SCENE? • YES DINO
5. WHAT PARTICULAR ACT OR OMISSION DO YOU CLAIM CAUSED THE INJURY OR DAMAGES? Give the name of the city/town employee causing the injury or damage, if known.
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ 1600.00 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: Amount: $
Item/Date: Amount: $
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $.
ESTIMATÉD PROSPECTIVE DÂMAGES, AS FAR AS KNOWN:
Amount: $
Item/Date:: Amount: $_
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: $
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) NAME: NAME:
ADDRESS: ADDRESS:
TELEPHONE: | ) TELEPHONE: | 1
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTOR(S) OR HOSPITAL(S) VISITED:
NAME: NAME:
ADDRESS: ADDRESS:
TELEPHONE: L TELEPHONE: ()
DATE: TIME: •AM •PM DATE: TIME: •AM 0 PM
9. PLEASE READ THE FOLLOWING CAREFULLY:
For all vehicle accident claims, place on the following diagram, the names of streets, including NORTH, EAST, SOUTH AND WEST directions. Indicate place of accident by "X" and by showing house numbers or distances to street comers. a cry/town vehicle was inyolved, designate by letter "A" location of the City/Town vehicle when you first saw it, and by "B" location of yourself or your vehicl when you first saw City/Town vehicle; location of City/Town vehicle at time of accident by "A-1" and location of yourself or your vehicle at the time of th accident by 'B-1" and the point of impact by "X*.
→ NOTE: IF THE DIAGRAM BELOW DOES NOT FIT THE SITUATION, PLEASE ATTACH A PROPER DIAGRAM SIGNED BY THE CLAIMANT.
CURB
*PARKWAY- - -
7 SIDEWALK
I HAVE READ THE FOREGOING CLAIM AND KNOW THE CONTENTS THEREOF; AND CERTIFY THAT THE SAME IS TRUE OF MY OWN KNOWLEDGE EXCEPT AS TO THOSE MATTERS WHICH ARE HEREIN STATED UPON MY INFORMATION AND BELIEF; AND AS TO THOSE MATTERS I BELIEVE THEM TO BE TRUE.
I CERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNAPURE OF CLAIMANT OR AGENT
JEAN M. HUBBARD MARCH 10,2022
TYPE OR PRINT NAME DATE
RELATIONSHIP TO CLAIMANT
NOTE: PRESENTATION OF A FALSE CLAIM IS A FELONY (CA PENAL CODE 72) RETURN CLAIM TO: RIALTO CITY CLERK'S OFFICE - 150 S. PALM AVE., RIALTO, CA 92376 Patriot Plumbing Services Inc.
3755 S Stoney Hill Rd
Washington, UT 84780 US
[email protected]
CITY OF RIALTO
2022 MAR 10 PM 3:01
INVOICE
RECEIVED
BILL TO CITY CLERK INVOICE 11834-5
Jean Hubbard DATE 10/22/2021
TERMS Due on receipt
DUE DATE 10/22/2021
DATE SERVICE DESCRIPTION QTY RATE AMOUNT
Services Called out for mainline clog. Pulled 1 1,600.00 1,600.00 toilets in two bathrooms to try to clear
could not clear. Installed two way clean
out system in yard and ran line to clear.
Tested all ok at this time.
PAYMENT 1,600.00
BALANCE DUE $0.00
PAID
3-10-2022
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RIALTO, CA Main Semer Line)