CITY CLERK'S DATE STAMP
CITY OF RIALTO
CITY OF RIALTO
LIABILITY
2022 FEB 11 PM 3: 30
CLAIM FOR DAMAGES
TO PERSON OR PROPERTY RECEIYED
CITY 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: 150S. Palm Ave., Rialto, CA 92376 Address: 290 W. Rialto Ave., Rialto, CA 92376
CLAIMANT INFORMATION:
Juan J. Hernandez
FULL NAME DATE OF BIRTH
Riätto Ca 923761
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 INJURY OCCUR? DATE: Still damaging Side iNe! Kand guttam mains logged
2. PLACE OF ACCIDENT (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. past yeurs to present, the street city tree infront of my property 15 Deen umaging the sidewalk. and now roots are making their way inside the main guttey drain causing the drain pine Clogged.
3. HOW DID DAMAGE OR INJURY OCCUR?
Side wald is been lift by the tree voots cusing Uneven sidewak and cand be dangerous it pedestrians cun trip and talle, also [Twil Continue to cause Clogeed drain it not fix Causiny moreexpences.
4. WERE POLICE AT THE SCENE? • YES• NO WERE PARAMEDICS AT THE SCENE? • YES ANO
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.
Ty or Klalto Trees ave causing damage.
ramget expenas caused biety tree $250 ~ rooter Service
Estimate Damage cost by an city pluming $ 5,200- anl $3687.95
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $. 7.98 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:/
Hem/Date: Repair empetdrain line 2/2/22 Amount: $_5,200= Hem/Date SerVise and Spot sewer druin line Verair 2/1/22 Amount: $ 3, 6 87.98 My expenses up to date 2/9/12 $ 250=
Cleaning-Undoggin Main drain line
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $ 9,137,98 ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN: My expenses up to dut $ 250= Hem/Date: Complete Repair sewer drain line 2-7-22 Amount:$ 5,200 Item/Date: Servic and Spot sewer duin line Vapaiy 2-7-Amount: $ TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: 19,13790
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) NAME: Juan Hernandez NAME: Lorena Kojas.
ADDRESS: ADDRESS: —
Rialto Cs 9237 Rate Ca 92376
TELEPHONE TELEPHONE:
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITALS) VISITED:
NAME: _ NAME:
ADDRESS: ADDRESS:.
TELEPHONE: ( 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 corners.
If a city/town vehicle was involved, designate by letter "A" location of the City/Town vehicle when you first saw it, and by "B" location of yourself or your vehicle 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 the 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 , side walk damage
Sewer lin-
Damag
7 SIDEWALK
My Property 2095
Lilac
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.
SIGNATURE OF CLAIMANT OR AGENT
Joan Hernander 2-10-22
TYPE OR PRINT NAME DATE
Claimant
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 All City Plumbing Estimate 33967625
ALL CITY 9447 Landon Way à 102, Rancho Cucamonga, Jel 33958645 California 91730 United States Estimate Date 2/7/2022
PLUMBING Customer PO
Billing Address Job Address
Juan Hernandez Juan Hernandez
Rialto, CA 92376 USA Rialto, CA 92376 USA
Estimate Details
Spot repair more the 5 feet deep
Task # Description Quantity Your Price Your Total
Sewer drain snot repair + ACP will call dig alert and have utilities marked off. Will camera and locate 1.00 $5,200.00 $5,200.00 shoring (Deeper than 5 problem area on sewer drain line, access and excavate to expose problem area by feet) hand or mini excavator. Drop in shoring to uphold all safety standards set by OSHA. Cut and remove damaged section of sewer line. Then replace damaged section with new approved ABS pipe material and special repair couplings thal are designed to secure pipe together and prevent leakage. After testing and proving proper grade and flow, will then refill native soil and provide proper compaction to prevent pipe from shifting.
1 year warranty
Potential Savings $0.00
Sub-Total $5,200.00
Tax $0.00
Total $5,200.00
Thank you for choosing All City Plumbing
THIS IS AN ESTIMATE, NOT A CONTRACT FOR SERVICES. The summary aboue is furished by (All City Plumbing Drain Cleaning & Rooter ] as a good faith estimate of work to be performed at the location described above and is based on our evaluation and does not include material price increases or additional labor and materials which may be required should unforeseen problems arise after the work has started. I understand that the final cost of the work may differ from the estimate, perhaps materially. THIS IS NOT A GUARANTEE OF THE FINAL PRICE OF WORK TO BE PERFORMED. I agree and authorize the work as summarized on these estimated terms, and i agree to pay the full amount for all work performed.
ESTE ES UN ESTIMADO, NO UN CONTRATO DE SERVICIOS.
Acepto que comprendo toda la información de este documento. El resumen anterior lo proporciona (All City Plumbing Drain Cleaning & Rooter ) como una estimación de buena te del trabajo que se realizará en el lugar descrito anteriormente y se basa en nuestra evaluacion y no incluye aumentos de precios materiales o mano de obra y materiales adicionales que puedan ser requerido en caso de que surjan problemas imprevistos después de que el trabajo ha comenzado. Entiendo que el costo final del trabajo puede diferir del estimado, quizás materialmente.
ESTO NO ES UNA GARANTÍA DEL PRECIO FINAL DE LA OBRA A REALIZAR. Acepto y autorizo el trabajo como se resume en estos terminos estimados, y arento pagar el monto total de todo el trabajo realizado.
DALKE THE BA TONY'S ROOTER SERVICE DATE/-210-2022 -
009) 596-8781 • (028) 381-0318 • DIRECT LINE: ($09) 876-8003
PROFERSIONAL SEWER-DHAN CLEANING SERVICE
CONTRACTOR'S LICENSE NO. 830838
DIRECT LINE TO SERVICE MAN: (809) 763-1417
ANDREW: (906) 681-8001
DOWN WORK COMPLETED
24 HOUR SERVICE
NAME Pan Manline Frem
lur lent to street
ADDRESS
tHen Don CAMERA
CITY KIAltO Denn Yin vent
hael Faunel Lure tinet
PHONE
TECHNICIAN
CA DRIVER LIC# APT# WAlk Fund Ruts
OTHER Entering senor lue
were
NAME
9o Feet From veni
ADDRESS PIE
CITY DRAIN CLEANING SERVICE
STATE - ZIp MAIN LINE LENGTH WARRANTY
SMALL LINE DESCRIPTION
PHONE
OTHER.
NOTE: QUE UPON RECEIPT OR WITHIN TWO WEE 0 5 P
LABOR S.
other charges the check may cause and all attorney fees caused from collection. PARTS S TONY'S ROOTER SERVICE can not be held responsible for any waste pipes under sink, lavs., TOTAL 240 2 etc. that may break, or leak due to age of pipe regardless of age. There is no guarantee on toilets - main line that are damaged in any way. This also includes tubs, lavs, shower, laundry lines and BILLED yard drains. MASTERCARD VISA
Customer's Signature:
WHITE/ ORIGINAL YELLOW/OFFICE PINK/ CUSTOMER GOLD/RETURN PAYMENT All City Plumbing Estimate 33969401
ALL CITY 9447 London Way & 102, Rancho Cucamonga, Job 33958648 California 91730 United States Estimate Date 2/7/2022
PLUMBING Customer PO
Billing Address ob Addres
Juan Hernandez Jan Hernande
Rialto, CA 92376 USA RIalto, LA 723/0 USA
Estimate Details
Spot repair
Task # Description Quantity Your Price Your Total
Sewer drain snot ACP will camera and locate problem area on sewer drain line, access and excavate to 1.00 $3,687.98 $3,687.98 repair expose problem area, cut and remove damaged section of sewer line. Then replace damaged section with new approved ABS pipe material and special repair couplings that are designed to secure pipe together and prevent leakage. After testing and do pr d f i tell alive soil and provide proper
compaction to prevent pipe from shifting.
1 year warranty
Potential Savings $0.00
Sub-Total $3,687.98
Tax $0.00
Total $3,687.98
Thank you for choosing All City Plumbing
THIS IS AN ESTIMATE, NOT A CONTRACT FOR SERVICES. The summary above is furnished by (All City Plumbing Drain Claning & Rootcr ] as a good faith estimate of work to be performed at the location described above and is based on our evaluation and does not include material price increases or additional labor and materials which may be required should unforeseen problems arise after the work has started. I understand that the final cost of the work may differ from the estimate, perhaps materially. THIS IS NOT A GUARANTEE OF THE FINAL PRICE OF WORK TO BE PERFORMED. I agree and authorize the work as summarized on these estimated terms, and agree to pay the full amount for all work performed.
ESTE ES UN ESTIMADO, NO UN CONTRATO DE SERVICIOS.
Acepto que comprendo toda la información de este documento. El resumen anterior lo proporciona [All City Plumbing Drain Cleaning & Rooter ) como una estimación de buena te del trabajo que se realizara en el lugar descrito anteriormente y se basa en nuestra evaluacion y no incluye aumentos de precios materiales o mano de obra y materiales adicionales que puedan ser requerido en caso de que surjan problemas imprevistos después de que el trabajo ha comenzado. Entiendo que el costo final del trabajo puede diferir del estimado, quizás materialmente.
ESTO NO ES UNA GARANTÍA DEL PRECIO FINAL DE LA OBRA A REALIZAR. Acepto y autorizo el trabajo como se resume en estos términos estimados, y acepto pagar el monto total de todo el trabajo realizado * H
Juan Hernandez
709. S. Lilac Ave SN BERNARDINO CA 923
Kalto Ca 92376 10 FEB 2022 PM 6 L
CITY OF RIALTO
2022 FEB | 1 PM 3: 30
RECEIVEL
CITY CLERK
Ricato City Clerk's Office
150 S. Palm Ave.
Rialto la 92376
S2376-648799