CITY CLERK'S DATE STAMP
CITY OF RIALTO
LIABILITY CITY OF RIALTO
CLAIM FOR DAMAGES 2023 AUG 15 AM IO: 32
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:
KEITH PHILLIPS
-
FULL NAME DATE OF BIRTH
HOME ADDRESS INCLUDING CITY, STATE & ZIP HOME TELEPHONE NO.
RALITO, CA. 92376
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 DAMAGE OR MUR OCCUR? DATE: 7/24/23 - TIME: 4:45
2. PLACE OF ACCIDENT (OCCURRENCE) BE SPECIFIC - Describe fully and (if applicable) locate on diagram on reverse side of this sheet.
EAST Side of
HOME FRONT gATE TO ENTER BACK YARD.
3. HOW DID DAMAGE OR INJURY OCCUR?
RIALTO POLICE DEPT. (SGT. FARMER) BROKE DOWN gATE 121
PURSUIT OF SUSPECT
4. WERE POLICE AT THE SCENE? *YES • NO WERE PARAMEDICS AT THE SCENE? • YESE 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.
GATE BROKEN DOWNBY RIALTO POLICE DEPT. SGT. FARMER
CIAIM # 932308338
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ 1,095 80 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: Amount:$_1,095°6
Item/Date: Amount: $_
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $ 1, 09500 ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: Amount: $_
Item/Date:
Amount: $_
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: $1,095.00
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) NAME: SGT. FARMER RIALTO POLICE DEfT. NAME:
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: (
DATE: TIME: • AM OPM DATE:
TIME: • AM • PM
9. PLEASE READ THE FOLLOWING CAREFULLY:
of accident by "X" and by showing house numbers or distances to street corners For all vehide accident claims, place on the following diagram, the names of streets, including NORTH, EAST, SOUTH AND WEST directions. Indicate place i 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
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.
1. ICERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
KEITH PHILLIPS 8/15/2023
TYPE OR PRINT NAME DATE
SELF
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 • WOOD
Remit to Main Office • MASONRY/ Installation
Main Office: CONCRETE
Date
2953 Jensen St. • VINYL
Corona, CA 92881 • IRON Temp
951-737-6162 Casa Valenzuela • CHAINLINK
• Estimate
CONSTRUCTION 0 LICE 103116 @ Contract/Invoice
Fully insured and Bonder
Estimator Jeremy Smith Cell (951) 808-2772 • [email protected] Est # Keith Phillips
NAME FENCE SPECIFICATIONS
ADDRESS
Rialto Style 5' wood fence
CITY - 92376
_ ZIP-
Color Redwood
HOME PHONE WORK PHONE N/A
JOB ADDRESS N/A _ CITY N/A Total Linear Footage
3.5 gate
EMAIL CUSTOMER - Footings - 10" x 24" (old footings left in ground) L Vinyl •Wood • iron • Chain Link
Description Height • Width • Length Thickness
Post 2 x 4 redwood
Rails 2x4
8386 Boards
X 1 × 6
Pickets
Wire
Single Gate 5.5 wide x 5 ' tall wood gate
Double Gate
-
Hardware S/S black
Bid Valid for 10 Days
Comments - 3% convenience fee added for all credit card transactions - Prior to install day Client is respoible to make sure all plants/Shrubs/ Decorative rocks/ Trash can are cleared from the fence line 2-3. X M Tear Out [2 Removal • Core Drill • Jack Hammer • Generator • Pool 10% deposit required on acceptance of quote. Contracts without deposits will not be valid until deposit received.
CUSTOMER PAYMENT due day of completion. Please walk the job with the foreman upon completion.
Payments not received upon completion will be charged 3% per day until paid. Customer has 1 year warranty for all materials and labor. Limited lifetime on vinyl materials from manufacturer.
ACCEPTANCE: The undersigned accepts the conditions and terms as stated hereon and agrees that this proposal becomes a contract between the two parties whose signatures appear below.
Purchaser agrees to pay Casa Valenzuela Construction 10% of total in case of contract cancellation. CVC assumes no responsibility of utility lines or We agree to furnish material, labor and installation complete as specified above. underground at property even with Dig Alert.
Customer X
Core Wall Release X
$ 950
Total Contract Amount Work Satisfied X
White - Work Order Yellow - Office Pink - Customer's Estimate/Sales Receipt Fusion Sign and Design - Form 102 Rev. 10/11/17 932308338
SGT. FARMER
- REF DAMAGED
GATE.
CLAIM TO CrY
E/S106 PEO GATE,