CITY OF RIALTO CITY CLERK'S DATE STAMP
LIABILITY CITY OF RIALTO
CHIY
CLAIM FOR DAMAGES
2023 SEP 25 PM 2: 04
TO PERSON OR PROPERTY
RECEIVED
CITY CLERK
1. Claims for death, injury to person, orto 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:
Brandon Robinson & Katherine Robinson
+
FULL NAME DATE OF BIRTH
Fontana, CA 92334e
F0117/ICO
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): Fontana, CA 92336
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: 9|5/23 TIME: 12pm - 2PMAN DIPM
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.
On Avala St travelling southbound in the far right lane immediately after exiting on Ayalast from the 210 Ewy east bound. A gardener was using whacker while fending touthe parkway which caused a rock to hit and crack
3. HOW DID DAMAGE OR INJURY OCCUR? the front passenger window.
While driving southbound on Ayala st in Rialto, a rock hit the passenger side (front) window of my 2013 Ford Explover which produced a large crack in the window. I was caused by the gardening service that was tending tothe
4. WERE POLICE AT THE SCENE? • YES X NO WERE PARAMEDICS AT THE SCENE? • YES NO awn adjacent to Ayalast.
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.
The gardening service personne were using weed whackers to trim the land scaping ad acent to the south bound lanes on Ayala st in Rialto.
In the process, rock were being flung into traffic which rich caused the damage to the
5. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage 205.81 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: _ Front Passenger side window Amount: §_ 205.81 Item/Date: Amount: $.
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $_ 205.81 ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: 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:
NAME:
ADDRESS:
ADDRESS:
TELEPHONE: | ) TELEPHONE: L)
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME: NAME:
ADDRESS: ADDRESS:
TELEPHONE: ( TELEPHONE: L
DATE: _ TIME: • AM • PM DATE: TIME:
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. 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.
Fay car Ayala st
CURB → south
210
PARKWAY gardener witha
weed wacker
SIDEWALK
ICER ORDE CLARE UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT JACENT
Brandon Rubinson 9/25/23
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 Superior Auto Styling
2203 4th St
Ontario, CA 91764
+1 9096363287 Superior
[email protected]
Auto Styling
BILL TO SHIP TO INVOICE # 43741
Brandon Robinson Brandon Robinson DATE 09/08/2023
CHECK IN REP DELIVERY TIME
BW IGC 9:00
Auto Glass Parts:Door Glass Parts 1 191.00 191.00T
13 Ford Explorer dd11830
SUBTOTAL 191.00
14.81 TOTAL 205.81
PAYMENT 205.81
BALANCE DUE $0.00
2023 SEP 25 PM 2: 04 CITY OF RIALTO
50 Auto Glass Warranty- Lifetime warranty on labor. 30 days on parts Window Tint Warranty- Lifetime warranty on film and workmanship.
Rock Chip/ Crack Repairs- Lifetime warranty never to spread.
Warranty Issues Done Mon. - Thurs. 9am-4pm