CITY CLERK'S DATE STAMP
CITY OF RIALTO
CITY OF RIALTO
LIABILITY
2023 APR -3 PM 3: 29
CLAIM FOR DAMAGES
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).
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:
Gabriel Dorantes
-
FULL NAME DATE OF BIRTH
Fontana ca92337
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):
3/13|23 : 9:24 •АМ Д PM
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE:_ TIME:
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. pepper heading towaras Baseline Ave Malto cu
Between Footh Bud Bascine Ave I made the repart
to the police Deparment
3. HOW DID DAMAGE OR INJURY OCCUR?
tradina Tawaras Busine onpepper Ave
othes on the stret
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.
Rialto ca potnales on the Road I cruse over them
inthe wight.
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $2628.28 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
stimate 413/2023 Amount: 268808
Item/Date:
Item/Date: Amount: $
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $2729.83 ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: 4-3-2023 Amount: $ 2729,83
Item/Date: Amount: $.
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: $2 729.83
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information attach additional pages, if necessary) NAME: I toor pictures of potholesumE and called the police ADDRESS: ADDRESS: _
TELEPHONE: | ) TELEPHONE: ()
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME: NAME:
ADDRESS: ADDRESS: _
TELEPHONE: ) TELEPHONE: L
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 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.
AVe CURB Etivanda Av
N pepper
PARKWAY
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.
GERTIEY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
riel Dorantes 4-3-2023
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 A 1 TIRES CITY OF RIALETRO Witer FEEX DRAFT
629 E FOOTHILL BLVD
RIALTO, CA 92376-5225 2023 APR - 3 Pa%: 22123 02:22 PM
Ph: (909) 874-2247 • Fax: (909) 874-2655
[email protected] RECEIVED
CITY CLERK
GABRIEL DORANTES (Authorizer) 2010 Lexus IS 250 AWD
CA V6-2.5L (4GR-FSE)
M:
Mileage: In 0 | Out 0
PART # QTY/HRS PRICE/RATE TOTAL
ITEM DESCRIPTION
Labor Control Arm: Replace - Front Suspension - Lower Control Arm - Custom Labor Rate 1.60 120.00 192.00 One Side
Note Custom Note:
Does Not Include: Wheel Alignment.
Labor Suspension Strut / Shock Absorber: Replace - Front Custom Labor Rate 1.40 120.00 168.00 Suspension - One Side
Labor Control Arm: Replace - Front Suspension - Upper Control Arm - Custom Labor Rate 1.20 120.00 144.00 One Side
Part upper control arm 2 140.00 280.00
Part control arm 350.00 700.00
Part strut 2 320.00 640.00
Part rotor and brake pad 1 250.00 250.00
Labor WHEEL ALIGNMENT A1 TIRES AND 1.00 100.00 100.00
WHEELS
Payment is expected at the time of completion. All parts are new unless otherwise specified. OEM means Original Equipment Manufacturer (Factory) part. The shop is not responsible for any damage to vehicle caused by theft, fire or circumstances beyond our control. The Shop Supplies and Hazardous Materials Fees represents costs to the motor vehicle repair facility for miscellaneous supplies or waste disposal. A vehicle storage fee will be charged daily for vehicles left on-site after 72 hours from notice of work completion. Replaced parts will only be saved or returned to customer upon request.
ESTIMATES ARE VALID FOR 30 DAYS.
Parts: $1870.00
Labor: $604.00
Shop Supplies: $0.00
HazMat: $0.00
Subtotal: $2474.00
Total Tax: $154.28
X Date 04-03-2023
Total: $2628.28
Customer Signature
Cesar's Auto Repair
145 S Mt Vernon Ave
San Bernardino, Ca 92410
(909) 889-5644
BAR AA214651 EPA Cal000182903
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2023 APR -3 PM 3: 29
Customer: Gabriel Dorantes Service Writer: Cesar
Address: Service Tech: RECEIVEL
City, State: CITY CLERK
Day Phone: VID:
Night Phone: Mileage: 226675
Fax:
Estimate Ref: 1370
Date: April 03, 2023
Time: 01:32 PM
Vehicle: 2010 Lexus IS 250 RWD V6-2.5L (4GR-FSE)
Part #/Labor Rate Qty Price/Time Extended
Description
Request for service,, Check front suspention, Diagnose: It need 1 500.00 500.00 front Lower Control Arm, upper control arm, front strut both side, front brakes pads,
123437874 Strut 148.98 297.96
m989080 Upper Control Arm 349.23 698.46
784394 Lower Control Arm 423.00 846.00
65.00 130.00
FR 83490 Brakes rotor
1 78.00 78.00
BP 479183 Brakes Pads
Labor Total 500.00
Parts Total 2050.42
Sub-Total 2550.42
Parts Tax 8.75% 179.41
Total $ 2729.83
Six mounts of warrenty or 6000 miles with ever comes first On transmission rebuilt. 30 days of warrenty On Used transmission and engine oil cooler seals. Engine replace labor 30 Day warrenty when customer supplys. 90 days of warrenty on engine replace shop supplys
One year of warrenty on water pump,
Brakes jobs one year warrenty on parts, labor 90 days.
alternator and starter motors replace one year warrenty. electrical repair no warrenty
It was a pleasure to repair you vehicle
Date
Signature