CITY OF RIALTO CITY CLERK'S DATE STAMP
LIABILITY CITY OF RIALTO
CLAIM FOR DAMAGES 2024 JUL - | AMII: 09
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:
SEAN CHOPHIN MArIN
FULL NAME DATE OF BIRTH
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 INJURY OCCUR? DATE: 2/7/24 TIME: 6:S5 I 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. 1) Intersection of Pepper Ave and Rialto Ave. Pothale was in the middle of the internation. 2) Northbound, left lane of Pepper Ave.
3. HOW DID DAMAGE OR INJURY OCCUR?
* inter and seat ped to tou am de as that were t as it a to water / Flooding.
4. WERE POLICE AT THE SCENE? • YES Z NO WERE PARAMEDICS AT THE SCENE? • YES X 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.
Driviny at regular speed 1 Potholes were completely coveral by water and were so large that poll wehicles colld not avoid them
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ 3711,33 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: Labor + Parts BLAKE MASTERS 3/12/24 Amount: $ 2139.09 Item/Date: Labor + Parts SPREEN HONDA 6/28/24 Amount $ 3711,33 TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $ 3711.33 ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: Lalur + Parts BRAKE MASTERS 3/12/24 Amount: $ 2/39.19 Item/Date: Labor + Parts SPREEN HONDA 6/28/24 Amount: $ 3711.33 TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: $ 3711.33
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: • AM 0 PM
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. f 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 vehick 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. * Sce attached
map.
CURB
AWAY
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.
ICERTEY JOR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
SEAN CMRISTOPHEN MARIN 6/28/24
TYPE OR PRINT NAME DATE
SeAf
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 Google Maps
Trouper vita
N Pepper Mediterranean
Mobile Home Estates
3 Gardens Peppertree Mobile
ome Park Home Park
Wonderland
Medical Dispensary
• GO Car Wash
E Rialto Ave E Rialto Ave E Rialto Ave W Rialto Ave W Rialto Ave W Rial Multiph lage potholes
Diretion of travel
Jimmy's Coin Car Wash
9 Paredes
Acacia Villa
Mobile Home Park
My
house
Google o
• AID TREE CARE
Golden Prime
painting services
Map data 02024 100ft L
*On 2/07/24 The Enterscutim @ Pepper Ave / Rialto Ave was completely tloaded. Water was about b inches dee, multiphe cars mad extremely hard inpoet with deep potholes that also damaged my car.
After this storm the entire intersection was so demaged and dangerous that it was completely repared.
Brake Masters #201 Invoice #221160
BRAKE 1705 W Lugonia Ave Page 1 of 2
MASTERS Redlands, CA 92374 03/12/2024 10:41 AM
909-792-0351
[email protected]
SEAN MARIN 2001 Honda Civic Advisor: 556 O.B. GRAND TOTAL: $69.95 Technician: 559 F.S.
Engine: 1.7L L4 (D17A2) ~ PAID
GAS FI
Plate:
Odometer In: 288968
Odometer Out: 288968
SERVICES
CHECK IN SPEC
SUBTOTAL: $69.95
customer hit potholes on both sides of the car which caused damage to the suspension Labor: $69.95
both sway bar links are worn down, left side booth is torn Parts: $0.00 both lower ball joints are worn, boot is torn Fees: $0.00 Sublet: $0.00
both outer tie rod ends are also worn.
rear upper control arms are worn.
alignment is out of specs
LABOR
inspection
Terms of Service: GRAND TOTAL: $69.95
ALL PARTS ARE NEW UNLESS OTHERWISE STATED Total Labor: $69.95
1. "YES, DO THIS WORK" Total Parts: $0.00
I hereby authorize the corresponding service to be done along with the necessary materials. Total Fees: $0.00
2. "YOU MAY DRIVE MY CAR ON PUBLIC ROADS" Total Sublets: $0.00 Brake Master staff may operate my vehicle for the purpose of testing, inspection, and Sales Tax: $0.00
3. "NO PAYMENT, NO KEYS" • PAID
An express lien is acknowledged on my vehicle to secure the amount of services thereto.
4. "ONLINE COMMUNICATION OK 03/12/2024 10:41 AM
I welcome email from Brake Master as a means of receiving copies of my estimate, work Paid by Credit Card - MASTERCARD: $69.95 order. and invoice.
5. "CARFAX REPORTING OK"
I Authorize Brake Masters to Communicate with Carfax about my vehicle.
6. I acknowledge notice and oral approval of an increase in the original estimated price.
7. "HERE'S MY SIGNATURE"
I endorse the attached digital image of my signature as equivalent to my written signature and as proof of my agreement to these six terms.
Reference estimate/Work Order #_
Authorization:
Brake Masters #201 Estimate #245446
BRAKE 1705 W Lugonia Ave Page 1 of 2
MASTERS Redlands, CA 92374 06/28/2024 3:39 PM
909-792-0351
[email protected]
SEAN MARIN 2001 Honda Civic Advisor: 556 O.B. GRAND TOTAL: $2,069.14 Engine: 1.7L L4 (D17A2)
GAS FI
Plate:
Odometer In: 1
SERVICES
Remove & Replace Suspension rear upper Control Arm
SUBTOTAL: $1,880.70
LABOR Labor: $1,098.00
Remove & Replace rear upper Suspension Control Arm Parts: $782.70 remove and replace lower ball joints Sublet: 50.00
remove and replace outer tie rods
remove and replace sway bar links
PARTS PART# QTY EACH TOTAL
rear upper Control Arm RK90351 2.0 $198.00 $396.00
outer Steering Tie Rod End GES3581 2.0 $49.35 $98.70
front lower Suspension Ball Joint GK90332 2.0 $69.00 $138.00 sway Bar Link MK90454 2.0 $75.00 $150.00
4 WHEEL ALIGNMENT
SUBTOTAL: $119.95
LABOR Labor: $119.95
4-WHEEL ALIGNMENT Parts: $0.00
Fees: $0.00
Sublet: $0.00
Tatal: Parts + Labor → 2069.14
+ Laspectina Fee → 67.95
$2139.09
CUST NO. TAX EXEMPT NUMBER CELL: 909-246-8477
CUST. P.O. NO. SHIP VIA SOLD BY INVOICE DATE INVOICE NO. 274034 CASH GLENN WEYNSCHENK 06/28/24 PQ56527
HOR
i İ SEAN MARIN
SHIP QTY B. O. CTY PART NUMBER / DESCRIPTION BIN LIST NET AMOUNT 0 51321-S5A-003 LINK, L. 012D1 44.99 44.99 89.98
LABOR 7.3 @ $189= 1379.70
51321-S5A-003 LINK, L. 012D1 44.99 44.99 44.99
51210-S5A-J10 KNUCKLE, SOP 742.99 142.99 742.99
51215-S5A-J10 KNUCKLE, SOP 742.99 742.99 742.99
51320-S5A-003 LINK, R. SOP 44.99 44.99 44.99
0 52390-S5D-901 ARM, RR. SOP 248.99 248.99 497.98
MASTERGARD VISA ATM
DISCOVER AMERICAN EXPRESS
NO GOODS WILL BE ACCEPTED
FOR CREDIT OR REFUND AFTER
SUBTOTAL 30 DAYS. ANY RETURNS MUST
ANY WARRANTIES ON THE PARTS AND/OR ACCESSORIES SOLD HEREBY ARE THOSE 2163.92 HAVE OUR PRIOR APPROVAL MADE BY THE MANUFACTURER. THE SELLER, SPREEN HONDA, HEREBY EXPRESSLY RESTOCK CHARGE 0.00 AND CANNOT BE ACCEPTED IF
DISCLAIMS ALL WARRANTIES, EITHER EXPRESS OR IMPLIED, INCLUDING ALL PACKAGING IS BROKEN OR IMPLIED WARRANTIES OF MERCHANTABILITY OR FITNESS FOR THE PARTICULAR TAX 167.71 UNSEALED. 20% HANDLING PURPOSE, AND SPREEN HONDA NEITHER ASSUMES NOR AUTHORIZES ANY OTHER CHARGE ON RETURNED ITEMS.
PERSON TO ASSUME FOR IT ANY LIABILITY IN CONNECTION WITH THE SALE OF THE NO REFUNDS ALLOWED ON PAY THIS AMOUNT 0.00 ELECTRICAL ITEMS OR SPECIAL
PARTS AND/OR ACCESSORIES. ORDER PARTS.
2331.63
•STOMER COPY
LOMA
-Honda TIND CORONA Spreen
ACURA
25050 Redlands Bivd. 1080 Pomona Road 8101 Auto Dr.
Loma Linda, California 92354 Riverside, California 92504 2a Linda, Califonia 92354 C0r051 280-109232 Loma Linda.
(909) 799-7070 (951) 462-2649 (909) 363-1000
* Note: Labor cost of $$1379.70 not included in the parts total.
Total labor + parts = $3711.33