CITY OF RIALTO CITY CLERK'S DATE STAMP
LIABILITY
CITY OF RIALTO
CLAIM FOR DAMAGES
TO PERSON OR PROPERTY 2023 JUL 25 AM 9: 05
RECEIVED
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 §9112). CITY CLER*
2. Claims for damages to real property must be filed not later than one (1) year after the occumence (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: 150S. Palm Ave., Rialto, CA 92376
Address: 290 W. Rialto Ave., Rialto, CA 92376
CLAIMANT INFORMATION:
Andrew Demetri Rodriguez
FULL NAME
DATE OF BIRTH
AZUSa CA.91702
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 MAURY OCCUR? DATE: July 15 2023 TIME: 5:21 DAM 0 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.
Eastbound on 1-210 between North Riverside Ave. and
North Pepper Are. exits.
3. HOW DID DAMAGE OR INJURY OCCUR?
Damage on front driver sido windshiuld due to debris on freeway because of a high speed chase by hiatto PD unit Please refer to case # 932307819.
4. WERE POLICE AT THE SCENE? & YES • NO WERE PARAMEDICS AT THE SCENE? • YES M 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.
Durina the hiah spurd pursue, oficers were on the left twy. shoulder and debris from the highway Hung ds the road
and causeo admade to mu venice front windshikia.
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ 1,288.65 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Hem/Date: 1/18/23 : windshield Amount: $_1,288.65
Item/Date: 1/20/23: windshield Amount: $ 1,87. 84
Safelite. AutoGlass
CITY OF RIALTO
Location Information 2023 JUL 25
Estimate 01841-916490 AM 9:05
Safelite #AK230020
576 N CITRUS AVE Org Date: 7/18/2023 CTU WO: 916490 RECEIVEL COVINA, CA 91723 7/18/2023 5:28 PM CITY CLER*
626-914-4416
Keyed By: 518
ANDREW RODRIGUEZ
Account Information
CONSUMER PARENT
127035 - 086780 --
Primary:
Alternate:
Year Make Model
Body Style Mileage
2021 HONDA ACCORD 4 DOOR SEDAN
Qty Part # Selling Labor
Kit
1 FW04794 GTYOEM $669.99 $60.00 $0.00
Replace with new - SOLAR~ACOUSTIC INTERLAYER~LDWS~FORWARD C 1 RECAL STATIC $0.00
$450.00 $0.00
Replace with new - ADAS STATIC RECAL SERV
1 RECYCLE FEE $0.00
$39.99 $0.00
Replace with new - RECYCLE FEE
Part Sub Total: $669.99
Labor Sub Total: $549.99
Sub Total:
$1,219.98
Sales Tax: $68.67
Total: $1,288.65
This ESTIMATE is good for 10 days from the date noted above.
THIS IS AN ESTIMATE ONLY
Your windshield is an Original Equipment manufactured part.
You will be prevented from operating your vehicle for approximately 1-hour after installation. ** CALL TO SCHEDULE WORK **
** 1-800-800-ASAP (2727) **
CITY OF RIALTO
Quote 340101/1305
Job Type: N/A Scheduled Date: N/A Scheduled Time: N/A AM 9: 05 LE STAR GLASS Bill To: ALOEIVED
Remit Payment To: CITY CLERA
Retail Customer All Star Glass, LLC
1845 Morena Blvd
San Diego, CA 92110
Customer Information Vehicle Information
Customer Name Andrew Rodriguez Year
E-mail 2021
Make Honda
Address Model
Accord
Ontario, CA 91761 VIN 1HGCV2F38MA024608
Telephone Unit #
Odometer
Bill To Retail Customer Policy Number
Date of Loss 0000-00-00
PO #
Qty UOM List Extended Part Number Description
Total
1.00 ea $956.83 $1,148.20 73111-TVA-A11 Windshield (Acoustic Interlayer, LDWS, Forward Collision Alert, $1,148.20
1.00ea N/A $125.00 SRI00600 Remove And Install
$125.00
1.00 ea $375.00 $375.00
RECAL-RTL-STATIC ADAS Recalibration (Static) $375.00
1.00 ea $48.00 $25.00 HAH000448 Adhesive (Fast-Cure Urethane/Dam/Primer, Fast-Cure Urethane/Dam/ $25.00
1.00 ea $63.23 $75.88 73151-TVA-A01 Moulding
$75.88
1.00 ea $7.38 $8.86 73150-TVA-A01
Moulding $8.86
2.00 ea $3.38 $4.06 73126-TVA-A01
Moulding (Windshield, Side) $8.12
Sales Tax $110.78
Total
$1,876.84
Notes
FEDERAL TAX ID# 47-3595252
CITY OF RIALTO
Snout ready a anile spit roare at replacemen a are new wind day seria. co.