Barnaby Wang
RECEIVED
MAY 0 9 2023
CITY CLERK'S OFFICE
May 3, 2023
Vernon City Clerk
Office of the City Clerk
4305 South Santa Fe Avenue
Vernon, CA 90058
Dear Vernon City Clerk:
Please see attached for the following for your review and claim processing - 1) Claim For Damages to Person or Property Form - City of Vernon 2) Pictures of the Potholes and Flat Tire Damages
3) Receipt Copy for Replacement Tires
4) Location/jurisdiction of the Potholes
We have reached out other jurisdictions -
1) City of Los Angeles - We submitted a claim on January 30, 2023 online. We initially thought that the location was in the City of Los Angeles. We received a denial letter dated April 4, 2023 stating that the claim should be filed with the County of Los Angeles and was provided the address to file the claim.
2) County of Los Angeles - We mailed in a claim form dated April 14, 2023 via USPS certified mail and return receipt. We received a denial letter dated April 26, 2023. We were subsequently informed that the jurisdiction of the claim falls in the City of Vernon. We were provided several sources by the County of Los Angeles, including the County of Los Angeles's Public Works Service Locator which is accessible to the public via the website address. We have attached the map in this claim.
Please let me know if vou need anything further to review and process the claim. I can be reached at Thank you for your assistance. I forward to hearing from you.
Sincerely,
Barnaby Wang
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CLAIM FOR DAMAGES RESERVE FOR FILING STAMP
TO PERSON OR PROPERTY CLAIM No.
INSTRUCTIONS
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 Sec.9112)
2. Claims for damages to real property must be filed not later than one (1) year after the occurrence. (Gov. Code Sec.911.2)
3. Read entire claim before filing.
See page 2 for diagram upon which to locate place of accident This claim form must be signed on page 2 at bottom
6. Attach separate sheets, if necessary, to give full details. SIGN EACH SHEET.
7. Claim must be filed with City Clerk. (Gov.Code Sec. 915a) TO: CITY OF VERNON CITY COUNCIL
Name of Claimant Age of Claimant (If natural person)
Barnaby Wang 48
Home Address of Claimant City and State Home Telephone Number Business Address of Claimant City and State Business Telephone Number Give address to which you desire notices or communications to be sent regarding this claim:
How did DAMAGE or INJURY occur? Give full particulars.
Potholes punctured two tires of the passenger vehicle.
When did DAMAGE or INJURY occur? Give full particulars, date, time of day, etc.:
January 18, 2023 - 8:00 PM
Where did DAMAGE or INJURY occur? Describe fully, and locate on diagram on reverse side of this sheet, where approximate, give street names and address and measurements from landmarks:
3911 E Washington Blvd. Vernon, CA 90058
Color photos of jurisdiction/location/map snapshot are attached to this claim form.
What particular ACT or OMISSION do you claim causedthe injury or damage? Give names of City employees, if any, causing the injury or damage, if known:
Potholes were unreasonably large and should have been maintained by the City.
Color photos are attached to this claim form.
What DAMAGE or INJURIES do you claim resulted? Give full extent of injuries or damages claimed:
Two flat tires - passenger side, front and rear. Color photos are attached to this claim form.
What AMOUNT do you claim of each item of injury or damage as of date of presentation of this claim, giving basis of computation:
$825.68 = Replacement of two flat tires. Receipt copy of replacement tires is attached to this claim form.
Give ESTIMATED AMOUNT as far asknown you claim on account of each item of prospective injury or damage, giving basis of computation:
2/9
Were you insured at the time of the incident? If so, provide name of insurance company, policy numbers and amount of insurance payments received:
Yes. AAA - I
No insurance payments were received because the amount that would be claimed is below the deductible.
Expenditures made on account of accident or Injury: (Date - Item) (Amount) January 19, 2023 - Two replacement tires - passenger side, front and rear. $825.68 Name and address of Witnesses, Doctors and Hospitals:
READ CAREFULLY
For all accident claims place on following diagram names of streets, including North, East. South, and West: indicate place of accident by "X" and by showing house numbers or distances to street comers.
NOTE:if diagrams do not fit the situation, attach hereto a proper diagram signed by claimant.
FOR AUTOMOBILE ACCIDENTS
JILL
71T
FOR OTHER ACCIDENTS
SIDEWALK
CURB/
CURB,
PARKWAY
SIDEWALK
I declaren dampenalty of perjury, that haufe of going, ior perding agy attace betats, is grue and corect.
Typed/Printed Name: Signature of Claimant or person filing on his/her behalf, giving Barnaby Wang relationship to Claimant:
5/3/2023
NOTE: ALL CLAIMANTS MAY BE REQUESTED TO BE EXAMINED AS TO THEIR CLAIM UNDER OATH. PRESENTATION OF A FALSE CLAIM IS A FELONY (CAL PEN. CODE SEC. 72). CLAIMS MUST BE FILED WITH CITY CLERK (GOV.CODE SEC. 915a). STATE LAW PROVIDES THAT IF YOU ARE NOT NOTIFIED OF ANY ACTION BY THE CITY OF THIS CLAIM WITHIN 45 DAYS OF FILING THEN THE CLAIM IS DEEMED DENIED (SEE GOV. CODE SEC. 911.6 & 912.4) 3/9 Rev. 814/16
Mr. Barnaby Wang
City of Vernon - Claim For Damages To Person Or Property Date and Time of Incident: 01/18/2023, 8:00 PM
Pictures of Potholes Pictures of Two Flat Tires
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CosTcO Date: 01/19/23 Invoice#: 4540381857
Time In: 10:57:20
WE TIRE CENTER MEMBER PURCHASE INVOICE Membership#: 111896742519
MEMBER INFORMATION VEHICLE INFORMATION
BARNABY WANG 2018 Tesla 3 Performance
Color: SILVER License:
Odometer: 49964
Wheel Torque: 129
Air Pressure: Front: 42 Rear: 42
ITEM# DESCRIPTION Qty SLIP PRINT
1209739 MICH PILOT SPORT 4S NO 2
ULTRA HIGH PERFORMANCE
235/35R20 92(Y) XL BSW
MSPN 08557
30,000 Mite Warranty
6850111 Michelin Installation 2
504595 Nitrogen Tire Inflation 4
7023 Tire Disposal Fee
866632 TPMS Service Pack Generic 4 SLIP PRINT RECEIPT
MEMBER 4: 111896742519
Costco # 454 TIRE SHOP ORDER * 4540381857
115 Technology Dr 2 e 354.99
Irvine. CA 92618 1209739 235/352R20 709.98 A
949-453-8230 CA STATE TIR 1.75
CA STATE TIR 1.75
BAR # ARD 27283 2 e 19.79
MICH INSTALL 39.98
2 ₽ 2.00
TIRE DISPOSL 4.00 A
4 8 2.92
SERVICE PK G 11.964
SUBTOTAL. 769.47.
TAX 56.26
**SPECIALAORDER*** 825.68
Costco Visa 825.68
9200045403818570 CHANGE 0.00
77.75% TAX 56.26
TOTAL TAX 56.26
NOTESTOTAL HUMPER OF ITEMS SOLD = 2
see Additional Notes..
CASHIER: JOCELYN S.
01/19/2023 10:57 454 95 9 80
*Inflation and Torque specifications are recommended by Manufacturer. — Best to Spare JOCELYN
_Static - Dynamic
_Blackwall _ Whitewall Sales Person 5/q Baser 1)
-
Date: 01/19/23 Invoice #: 4540381857
COSTCO
Time In: 10:57:20
BE TIRE CENTER Membership #
ADDITIONAL NOTES
* To Access your Michelin Tire Warranty Intormation, and to register the DOT numbers for new tires purchased, visit the links below. * Michelin Tire DOT Registration Web Address - https://www.michelinman. com/registertires
* Michelin Tire Warranty Information Web Address - https://www.michelinman. com/auto/assistance/warranty
* Read and follow all tire maintenance requirements outlined in the Tire Manufacturers' Warranty booklet provided at the time of purchase by hard copy or by reference to the Manufacturer's website.
6/1
3913 E Washington Bivd
Los Angeles, Califomia
Google Street View
Feb 2023 See more dates
•E-Washington Blvd
Union Pacific Railyard
- UPACR/9103
U.S. Lubricants
- Street View • Photo Path • Photo Sphere
Click highlighted areas to see images Leam more • CAT Scale Truck stop
Image capture: Feb 2023 © 2023 Google United States Terms Privacy Report a problem 7/9
ZIP Code™ by Address
You entered
911 E. WASHINGTON BLV
OS ANGELES C
If more than one address matches the information provided, try narrowing your search by entering a stres ddress and, if applcable, a unit number. Edit and search again 3911 E WASHINGTON BLVD
VERNON CA 90068
ARMIER ROUTE COLITY DELIVERY POINT CODE
C0S4 LOS ANGELES
HOOK DIan COLBUERCIAL MAL RECENA LACT
AGENCY
N
•LOT ASCENONODESCE RECORD TYPE CODE
HOICATOR
PUB HAINE DEPALLT PLAG
EWS FLAG DPV CONPIMATION INDICATOR
Look Up Another ZIP Code™ Edit and Search Again
EUSPS.COM
Source: United States Postal Service
Link to L.A. County Public Works service locator:
https://dpw.lacounty.gov/general/servicelocator/?addr
Service Locator
Enter address and press the Search Location button.
To find services in your area, press the FIND SERVICES button. 3600 E Weshington Divd, Vernon. CA 90058, USA Search Lecation Incorporated Please select your services: • Construction Utitties Road @ Transt (FIND SERVICESI Map Satellite
Services Located
Location:
3888 E Washington Blvd, Vernon, CA 90058, USA
ROAD
Union
Road Closures
Contact city/community of Vernon
(223) 583-8811
www.cityolvemon.org
Pothole and Roed Debris in the Road
+ Contact city/community of Vernon
(323) 583-8811
www.cityofvernon.org
AraTe
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CILA DOCTO
LE NAS
SALMA AV
132
3000. S ROWA SEAS
RENA SOLST. DENNISON ST
HUNTER ST 132A 01131
CALADA ST SANTA ANA FW
1318 CA COMM HOSE
E OLYMPIC BLVD-
E OLYMPI
3400 Al
BLVD 58 E PIOO BLO 142
ST LUGG S DITMAN AV CAV S HERBERT
E 14TH ST S INDIANA ST S ALMA AV S MOKS AV S EASTMAN S GAGE S RECORD AV
UNION PACIFIC AV LA PU
EMERY SYS UNION PACIFIC AV
4000
Angeles S HICKS AV DEDEAUX WY
HEROES
CONTESSA DR
MOAKES ST
HOBART
: WASHINGTON.BL.VD.
SHELAST **
§ PACIFIC WY- E WA
E26TH ST
Illustration of city limits in the vicinity of the incident location provided (3911 E. Washington Boulevard):
Pink = City of Vernon
Brown = City of Commerce
White = City of Los Angeles
• Yellow = County of Los Angeles
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