CITY OF RIALTO CITY CLERK'S DATE STAMP
LIABILITY
CITY OF RIALTO
CLAIM FOR DAMAGES
TO PERSON OR PROPERTY 2024 AUG - | AM||: 47
RECEIVED
1. Claims for death, injury to person, or to personal property must be filed not later than six 6) months after the occurence (Gov. Code 5911.5,Y 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., Rialto, CA 92376
Address: 290 W. Rialto Ave., Rialto, CA 92376
CLAIMANT INFORMATION:
Lou Barvais
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 13141 Iroquois RD (if different from home address provided above): APPle Valley CA 92308
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: 7/25/2024 Between TIME: 3-5 • AM 2PM
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. 1815 (lac Rialto CA 92314 ,
by Fire Dept
3. HOW DID DAMAGE OR INJURY OCCUR?
=as leak could not
Were broke to get eul petret in the has the pindaws
Smell Leak
4. WERE POLICE AT THE SCENE? EYES • NO WERE PARAMEDICS AT THE SCENE? YES ANO
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
Lialto fire Dept . Only way to get in wasto
pirat windows
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage § Linsure HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: Windaus on Raise Amount: $ Ur Sure
Item/Date: 725/2024 Amount: $ Un sure
3 29
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: §linsure ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Remble: Ill hide le essa de Amont Replacema
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: (epla(ec)
NAME: Rialto Fire Dept
ADDRESS: Rialto PI ADDRESS:
20324 CITY
TELEPHONE: TELEPHONE: _) AUG - / OF
8.IF IF INJURED, PROVIDE NAME, CONTACT AND AND DATE/TIME DOCTORS) OR HOSPITALS) VISITED NAME: No Injury>
ADDRESS: ADDRESS:
TELEPHONE: ( TELEPHONE: L)
DATE: TIME: DATE: _TIME: •AM • PM
9. PLEASE READ THE FOLLOWING CAREFULLY:
Forall 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. 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 vehic hen 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 t 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.
No Vehicle
clains
CURB
PARKWAY
7/F 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.
I CERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
Naney Barvais 7/30/2024
TYPE OR PRINT NAME DATE
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 Nancy Barvais 56:3E RDMOCA :923
781 S. Lilac 31301:2024 :PM41
Ricilto CA
92374
Rialto City elerk's office CITY CLERK RECEIVED 2024 AUG - | AMI|: 47 MIOE RIALTO 150S Palm Ave
Rialto CA 92374
92375-648799