CITY OF RIALTO
2023 FEB 15 AM||: 38
RECEI
CITY OF RIALTO CHEM COEMSDE STAND
LIABILITY
CLAIM FOR DAMAGES
TO PERSON OR PROPERTY
1. Clams are death, raly da person on to pertosal property sust be fled mur later that sik motts after the eccupace /Ger. Cade 9911.21
2. Cams toe damages to peat propery must be Med not satee than one (1) yeap aftee the occupance Gtre Code 99112. 3 READ ENTIRE CLAIM FOR BEFORE FILING RETURN TO:
A ATTACH SEPARATE SHEETS, IF NECESSARY. 10 GIVE FULL DETALS Rialto City Clerk's Office Mail: 1505. Palm Ave., Rlaha, CA 92376
Address: 290 W. Rialto Ave., Rialle. CA 92378
CLAIMANT INFORMATION:
John viggiano
FULL NAME
DATE OF BIRTH
HOME ADDRESS INCLUDING CITY, STATE & ZIP
HOME TELEPHONE NO.
BUSINESS ADDRESS INCLUDING CITY, STATE & ZIP
BUSINESS TELEPHONE NO.
ADDRESS AT WHICH CLAIMANT DESIRES TO RECEIE
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM
(i different om home address provided above):
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: _ January 4 2023 TIME: 19:30 _DAM 2 PM
2. PLACE OF ACCIDENT (OCCURRENCE) BE SPECIFIC - Descrite fully and iN appicable) locate on alagram on reverse side of this sheet. Where appropelate, give street names and addresses, measurements and landmants.
Foothill / Cedar median @Food 4 Less
up into the air into the on coming traffic Well trying to make a left turn the median did not give me time to merge striking the curb sending me
3. HOW DID DAMAGE OR INJURY OCCUR?
HITTINg cuab IN Left TVRU LANe
4. WERE POLICE AT THE SCENE? • YES NO WERE PARAMEDICS AT THE SCENE? • YES GI 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.
Left-hand turn lane is too short to merge no reflectors the curb is damaged from multiple crashes I've seen reflectors replaced since then and the curb continues to be hit TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIMF RIALTO $ $1223 ESTIMATED PROSPECTIVE DAMAGES. AS FAR AS KHOWN:
January 15 2023 2023 FEB 15 AMII: 38
Hem/Date
Amount S
Item Date RECEIVED
GITY CLERK Amount S
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: S1223
$.
7 WITNESSES TO DAMAGE OR INJURY is alpersons socato haventorator attach statonal bages necessary. "AM:: AAA towing company
NAM:
ADD LEA
Progressive towing
ЕтОа: 800 776 2778
TEENSE L
& IF INJURED PROVIDE NAME. CONTACT INFORMATION AND DATE TIME DOCTORIS OR HOSPITALS) VISITED:
NAVE:
NAME
ASE RESS.
ADDAL35.
TELL DRU
TELL Lİ
DA E
DAIL — lIL.
9. PLEASE READ THE FOLLOWING CAREFULLY:
Fal cabice acedart ten place on the fulles da gam, the names of sanets tude VORT, EAST SCUTH AND WEST desce-s locate piace er acedert gy and by showing house natters to distances to sheet copters. a cer toe vehicle was mclet designate Do ither Alecabon of me City Town vehicle when dos Sest saw e, and by B'lacation of yoursel co veave de scent by and and the condo pest to X
• NOTE: IF THE DIAGRAM BELOW DOES NOT FIT THE SITUATION, PLEASE ATTACH A PROPER DIAGRAM SIGNED BY THE CLAIMANT.
CURB
PARKWAY
SIDEWALK
HAVE READ THE FORLOLD CLAM AND NO THE CONTENTS THERELF AN CERTIFY HA• HE SANE IS TRUE OF 1R OWN ONCEDE ED LEP: AS TO
HE ASTER ONE EP SED OF DAD BEE AND HEATER I BELIE THEN ROBE MILE
ARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT
SIGNATURE OF CLAIMANT OR AGENT
John Viggiano February 7. 2023
TYPE OR PRINT NAVE
DATE
RELATIONSHIP TO CLAMANT
SN NARDINO CA 923
Mr. John Viadiana
13 FAR 2093 PM 9. 1
Tonna, CA 92335-5100
FOREVER / USA
Reets CiTY
Maintenare + Faciaties
RECEIVED
City of Rialto
FEB 1 4 2023 335W RIAlTO Ne CITY
• Maintenance & Facilities RIatE C$ 92376 2023 FEB 15 AMII: 39 CITY OF RIALTO • Engineering Services CLERK
92875-584235