CITY OF RIALTO CITY CLERK'S DATE STAMP
LIABILITY
CITY OF RIALTO
CLAIM FOR DAMAGES
2024 MAR 26 PM I: 41
TO PERSON OR PROPERTY
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). CITY CLERK
2. Claims for damages to real property must be filed not later than one (1) year after the occurrence (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 Offic Mail: 150 S. Palm Ave., Rialto, CA 9237(
Address: 290 W. Rialto Ave., Rialto, CA 92376
CLAIMANT INFORMATION:
Maria de Jesus Gonzalez Magana
FULL NAME
DATE OF BIRTH
HUME AUUKESS 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 INJURY OCCUR? DATE: 02/27/2024 TIME: 2:58 7 AM OPM
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.
The place of accident occured at my residency at iBSoN Willow Are in rialto CA 923 le due to a city tree infront of my home
3. HOW DID DAMAGE OR INJURY OCCUR?
Damage occured because all water (Sewege) came out of shower drainage and toilets, Causing damage in both bathrooms such as the floors and fixures. All due to tree roots that damaged the main pipes of my house.
4. WERE POLICE AT THE SCENE? •YES//NO WERE PARAMEDICS AT THE SCENE? YES DINO
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 tree roots from tree in the city of Rialto CA 9237l Caused damage to the main pipe lines of my hume.
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ 7,500° HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: _ 4/24/23 Amount: $ 7,50000
Item/Date: Amount: $
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $ 7,500°° 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: Marria Curena NAME:
ADDRESS:
ADDRESS:
Rialto, CA 92374
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:
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 comers.
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.
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 HERE STATED UPON MY INFORMATION AND BELIEF; AND AS TO THOSE MATTERS I BELIEVE THEM TO BE TRUE. -. -7) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAYANT OR AGENT
LARIA 3/26/24
TYPE OR PRINT NAME
DATE
Sel-
RELATIONSHIP TO CLAIMAN
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 C'ASTICIO EMPIRE PlUMBiNG INC
Contractors Invoice
WORK PERFORMED AT:
"MARIA GONZALZ
DAIL YOUR WORK ORDER NO.
OUR BID NO.
DESCRIPTION OF WORK PERFORMED
KUPACES SONER LINE TOM UNDERE
house to the
3" PIE 4" A5S
"KLINE WATCR MAIN PIPE APPRUX. 755.
0Fl% WVC sell 40 = W/4 COPPER
• foots In Hi d MAiN tiNE WinE TUtt
KOOTS CAUSETS BY ThE biG TRiE TOSAUSET
I the FrONT.
All Material is guaranteed to be as specified, and the above work was performed in accordance with the drawings and specifications provided for the above work and was completed in a substantial workmanlike manner for the agreed sum of UEN LUNDRED 6 C
_Dollars ($
This is a •Partial •Full invoice due and payable by: _
Month Day Year
in accordance with our Agreement Proposal No. Dated
Month Day Year
al adams TC8122
11-12
-CIV RIALTY
)1:02:58 PM / 02-27-2024 00 C
2:45:26 PM / 02-27:2024