CITY OF RIALTO CITY CLERK'S DATE STAMP
LIABILITY
CITY OF RIALTS
CLAIM FOR DAMAGES
TO PERSON OR PROPERTY 2024 MAR 21 PMI2:14
RECEIVE
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). HIY 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 Office Mail: 150 S. Palm Ave., Riatto, CA 92376
Address: 290 W. Rialto Ave., Rialto, CA 92376
CLAIMANT INFORMATION:
LARRY H. TA
FULL NAME
DATE OF BIRTH
HOME AUDRESS 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):
MANY MONTOF SINCE
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: ROOTS GROWTH City plANT TIME:
• AM • 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.
ROOTS GROWTH iS DAMAGiNE FOUNDATiONS iN BACK YARD INTO FORRiDATIDiNS OF POOL
ALL SPRINKLER DAMAGE, BROKEN ALL CONCRETE, AND MORE FENCE
3. HOW DID DAMAGE OR INJURY OCCUR?
ROOTS DAMAGE OF bACK YARD FOUNDATiON INCLUDiNG SWImmiNG POOL AREA
4. WERE POLICE AT THE SCENE? •YES/NO WERE PARAMEDICS AT THE SCENE? •YES MNO
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 CiTY OF RIALTO TREE ROOT'S GROWTH ONTO MY PROPERTY, AND CiTY OF RIALTO REMOVED THEM ON 9/12/23 by DEVELOPMENT OFFiCE
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $3,300,00 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: 5/01/23 ROOTS DIGGiNG DEEP 2 FEETS Amount: $ 1900.00 Hem/Date: RapAiR CONCRETE, bRiCKS, LAbER Amount: $ 2/00.00 TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: 3300.00 ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
tem/Date: _ 1700.00
Amount: $
Item/Date: 9/15
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: Amount: $ 2800.00 4500.00
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) NAME: PHLING K TANGUYEN NAME: Alejandio Rochi i=
ADDRESS: -
RALTO C'A CL376 ADDRESS: -
Kulta (1 923zie
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 0 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 comers. 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 vehicl nen 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 th 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
CACTUS AVE
BAGELINE
PARKWAY
THORONA HENCE (IREE) SIDEWALK
RIALTO CA 07237L
THOSE MATTERS WHICH ARE HEREIN STATED UPON MY INFORMATION AND BELIEF: AND AS TO THOSE MATTERS I BELIEVE THEM TO BE TRUE 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 \ I GERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE Ur ULMIYANI UK AGENI
LARRY H. TA 3/21/24
TYPE OR PRINT NAME
MYSELE
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 RECEIPT No.
5/01/2023 777878
DATE ....
FROM Larry Ta $1,200
One Thousand Two Hundred LuDOLLARS
BFORRENT Pool Structural Repair
ACCT. OCASH
PAID FROM
O MONEY ORDER
DUE CREDIT CARD
¡ BY Mik Saly
415906
CUSTOMERS ORDER NO DEPARTMENT
15 9/15/23
NAME
LARiY H. TA
ADDRES
RIALTO 0492376
SOLD BY GOD CHARGE ON ACCI MOSE RETD PAID OUT
QUANTITY DESCRIPTION PRICE AMOUNT
Asol iS/2L 2100/