CITY OF RIALTO CITY CLERK'S DATE STAMP
LIABILITY CITY OF RIALTO
CLAIM FOR DAMAGES 2022 MAY -4 PM I: 38
TO PERSON OR PROPERTY
RECEIVED
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).
3. READ ENTIRE CLAIM FOR BEFORE FILING RETURN TO:
4. ATTACH SEPARATE SHEETS, IF NECESSARY, TO GIVE FULL DETAILS Rialto City Clerk's Office Mail: 150 S. Palm Ave., Rialto, CA 92376
Address: 290 W. Rialto Ave., Rialto, CA 92376
CLAIMANT INFORMATION:
Jason Hernandez
FULL NAME -
DATE OF BIRTH
4 HOME ADDRESS INCLUDING CITY, STATE & ZIP HOME TELEPHONE NO. 1 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: 01/10/2022 8
TIME: XAM D PM
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.
A camera inspection was required by Rooter Hero to figure out why toilets and shower was not draining not fluching.
They had to excavate 3x3x3 section of front yard to expose sewer line. They removed section and installed 4" cleanout access. Included Additional camera inspection.
Icluded backfilling. City tree on the street on 1936N. Alice sitting on top of city sewer the roots grew into home plumbing and tree root bent plumbing pipes and caused plumbing to get backed up and required replacing of plumbing. Please note tree was asked to be removed by the City to prevent from future damage to home plumbing Tree was removed on 4/25/2022 as city employee claimed tree was on city sewer.
3. HOW DID DAMAGE OR INJURY OCCUR?
City tree on the street on 1936 N. Alice sitting on top of city sewer the roots grew into home plumbing and tree root bent plumbing pipes and caused plumbing to gef backed up and required replacing of plumbing.
4. WERE POLICE AT THE SCENE? •YES NO WERE PARAMEDICS AT THE SCENE? •YES NO
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 $3,825.00 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: 1/18/2022 3,825.00
Amount: $
Item/Date: Amount: $
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: 3,825.00 $
ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: 1/18/2022
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: Technician 5204 Byron Franco
NAME:
ADDRESS: Rooter Hero Plumbing
ADDRESS:
4650 Arrow Highway C-1 Montclair, CA 91763
TELEPHONE: ( 888-929-4376 TELEPHONE: | )
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME: NAME:
ADDRESS: ADDRESS:
TELEPHONE: L TELEPHONE: | )
DATE: TIME:
DATE: TIME: • AM • 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.
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
CITY CLERK RECEIVED CITY OF RIALTO
PARKWAY
SIDEWALK PH I: 3
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.
Yvette Saldana
SIGNATURE OF CLAIMANT OR AGENT
Yvette Saldana 4/26/2022
TYPE OR PRINT NAME DATE
Wife
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 Jason Hernandez
SN BERNARDINO CA 923
2 MAY 2022 PM6 L
CITY OF RIALTO
2022 MAY -4 PM |: 38
RECEIVEL
CITY CLERK
Rialto City Clerk's Office
ISO S. Palm Ave
Rialto, CA 92376
92376-848799