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)
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.
Attach separate sheets, if necessary, to give full details. SIGN EACH SHEET.
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)
Cesar Sanchez Sanchez 29
Home Address of Claimant City and State Home Telephone Number Business Address of Claimant City and State Business Telephone Number
NIA NIA
Give address to which you desire notices or communications to be sent regarding this claim:
How did DAMAGE or INJURY occur? Give full particulars. On Tuesday, June 6, 2023, I was driving on East Vernon Avenue. I was driving on the left lane. About 10 feet before approaching Hawthorne Avenue there were 3 pot holes about 2-3 feet Prom each other that caused significant damage to my vehicle. I was able to capture this on my dashcam and have attached an image trommy dashcam to this form.
When did DAMAGE or INJURY occur? Give full particulars, date, time of day, etc.:
The damage occured to my vehicle between vernon Avenue and Hawthor he Avenue on tuesday for 62023 and mate agra on rese
y, andlocate on diagram on reverse side of this sheet, where approximate, give street names and address and measurements from landmarks: The damage occurred on the left lane of East Vernon Avenue approximatley 10 feet before approaching Hawthorne Avenue.
What particular ACTor OMISSION do you claim caused the injury ordamage? Give names of City employees, if any. causing the injury or damage, if known: The City of Vernon failed to fix the 3 potholes located between 3ft from each other on the left lane on East Vernon Avenue as you approach Hawthorne Avenue.
hat DAMAGE or INJURIES do you claim resulted? Give full extent of injuries or damages claimed: My vehicl uftered major damage tren the 3 potholes causing total loss of tine pressure wheel. Both items needed to mete replaces un! as a crack on the rim of my front ight complete reDlacement.
WhatAMOUNT do you claim of each item of injury ordamage as of date of presentation of this claim, giving basis of computation: Upon taking my vehille to get repaired, I was billed for a total of $1,137.91. I have attached the bill to this form.
Give ESTIMATED AMOUNT as far as knownyou claim on account of each item of prospective injury or damage, giving basisor computation: I Was billed $ 1,137.91 for the repair of my front right tire and my front night rim replacement.
Were you insured at the time of the incident? If so, provide name of insurance company, policy numbers and amount of insurance payments received:
Auto Insurance. No claim has been filed with insurance.
Expenditures made on account of accident or Injury: (Date - Item) (Amount) 1113790 Wednesday, June 7, 2023
NA Dashcam
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 corners.
If City Vehicle was Involved, designate by letter "A" location of City vehicle when you first saw it, and by "B" location of yourself or your vehicle when you first saw City vehicle; location of City vehicle at time of accident by "A-1" and location of yourself or your vehicle at the time of accident by "8 1" and the point of Impact by "X." NOTE: If diagrams do not fit the situation, attach hereto a proper diagram signed by claimant.
FOR AUTOMOBILE ACCIDENTS
/ L
FOR OTHER ACCIDENTS
SIDEWALK
CURB/
CURB›
PARKWAY
SIDEWALK
I declare, under penalty of perjury, that the foregoing, including any attachments, is true and correct.
Typed/Printed Name: Signature of Claimant or person filing on his/her behalf, giving Date:
relationship to Claimant:
Cesar Sanchez Sanchez 07/31/23
NOTE: ALL CLAIMANTS MAY BE REQUESTED TO BE EXAMINED AS TO THEIR CLAIM UNDER OATH. PRÊSENTATION OF A FALSE CLAIM IS A FELONY (CAL.
PEN. CODE SEC. 72). CLAIMS MUST BE FILEDWITH CITY CLERK (GOV. CODE SEC. 915a). STATE LAW PROVIDES THAT IF YOU ARE NOT NOTIFIED OF ANY Customer Information Vehicle Information
SANCHEZ.CESAR
2018 MB CLA250
VIN#:
Color #: 787
Home Phone #:
Cell Phone #: Mileage In/Out #: 38311/38311
Contact Phone #:
Email Address:
Job # A Labor Total: $ 29.95
CUSTOMER STATES THAT THE RIGHT FRONT TIRE HAS GONE FLAT. PLEASE CHECK AND ADVISE.
TIRE SIZE IS 225/40R18 PIRELLI CINTURATO P7 A/S MOE BL BW PN: BQ8401792. CUSTOMER HAS IAS WARRANTY AT 800-346-6469.
Cause: replacement of right front wheel and tire. AUTH # SA177887-2174964 TIRE $ 218.90 WHEEL $ 518.40 LABOR $ 20.00 MISC $ 6.75 TAX $
70.38 TOTAL AMOUNT AUTH $ 834.43. FOR PAYMENT FAX TO 512-257-4777 EMAIL: CLAIMS@ IAAWG.COM. "CUSTOMER TO PAY DIFFERENCE 385.00 PLUS TAX"
TIRE CUSTOMER REQUEST ONE TIRE REPLACEMENT - ELIGIBLE FOR FREE TIRE ROTATION EVERY 5.000 MILES FOR THE LIFE OF THE
REPLACED TIRE(S) ONLY AT DTLA MOTORS
Tech Number: 263501 Labor Type: CEXP
Part Number Part Description Qty List
Parts Total: $ 1,100.21
0-8-40-1792 PIRELLI 1 $ 254.00 $ 254.00
225/40A18 SKU
2498200 92H
246-401-04-00- EXCHANGE DISK 1 $ 846.21 $ 996.21
7X21 WHEEL
38311 replacement of right front wheel and tire right front wheel and right front tire wee replaced due to side wall damage new wheel and tire have been mounted and balanced onto front right of vehicle old dot f/r 93 4u t982 2921 new dot f/t 93 4u 1982 0323 Misc Total: $ 7.75
Job # A Total $ 1,137.91
Job # B Labor Total: No Charge
CHECK AND ADJUST TIRE PRESSURE TO FACTORY SPECIFICATIONS PER ARB REGULATION 17 CA ADC 95550
Cause: psi
•OEM means Original Equipment Manufacturer (factory) Parts | All parts are New unless specified otherwise. http://www.los-angeles.mercedesdealer.com Order Open Date: 2023-06-07 Correction(s):
PSI CHECK AND ADJUST TIRE PRESSURE TO FACTORY No Charge SPECIFICATIONS PER ARB REGULATION 17 CA ADC 95550
Tech Number: 263501 Labor Type: 1
Part Number Part Description Qty List
Parts Total: No Charge
38311 psi CHECK AND ADJUSTED TIRE PRESSURE TO FACTORY SPECIFICATIONS FRONT 38 PSI, REAR 34 PSI Misc Total: No Charge
Job # B Total $ 0.00
Job # C Labor Total: No Charge
PERFORM COMPLIMENTARY MULTI-POINT INSPECTION - COPY PROVIDED UPON REQUEST--USE
LINK TO PAY FOR CONTACTLESS TRANSACTION-WE DO NOT TEST DRIVE VEHICLES WITH TINTED
WINDSHILEDS
EXPRESS- PERFORM MULTI POINT INSPECTION No Charge
Tech Number: 263501 Labor Type: 1
RBELONG PLEASE DOUBLE CHECK TO MAKE SURE ANY PERSONAL No Charge BELONGINGS HAVE BEEN REMOVED FROM YOUR VEHICLE. MERCEDES
BENZ OF LOS ANGELES IS NOT RESPONSIBLE FOR ANY BELONGINGS LEFT IN YOUR VEHICLE.
Tech Number: 99 Labor Type: 1
CLIAMS PLEASE BE AWARE INSURANCE CLAIMS MUST BE PAID IN No Charge FULL BEFORE A VEHICLE CAN BE RELEASED.
Labor Type: 1
COMM -My signature on the repair order consents to receive auto dialed, pre- No Charge recorded and artificial voice marketing and text messages on behalf of the dealer.
Also consents to future marketing by email and text.
Tech Number: 99 Labor Type: 1
Part Number Part Description Qty List
Parts Total: No Charge
Misc Total: No Charge
Job # C Total $ 0.00
Job # D Labor Total: No Charge
COMPLIMENTARY AUTOMATED CAR WASH- EXTERIOR WASH, VACUUM INTERIOR LESS TRUNK,
CLEAN OUTSIDE OF WINDOWS- DTLA MOTORS IS NOT RESPONSIBLE FOR LOOSE / DAMAGED/ OR
PREVIOUSLY REPAIRED BODY PANELS OR PAINT
Cause:
Correction(s):
WASH COMPLIMENTARY AUTOMATED CAR WASH- EXTERIOR WASH. No Charge
VACUUM INTERIOR LESS TRUNK, CLEAN OUTSIDE OF WINDOWS- DTLA
MOTORS IS NOT RESPONSIBLE FOR LOOSE / DAMAGED/ OR PREVIOUSLY
REPAIRED BODY PANELS OR PAINT
Tech Number: 263501 Labor Type: 1
Part Number Part Description Qty List
Parts Total: No Charge
Misc Total: No Charge
Job # D Total $ 0.00
Miscellaneous
Job # PO # Description
9997 TIRE DISPOSAL
A 9997 TIRE TAX
A 9997 WHEEL KIT
Miscellaneous Total: $ 7.75
RO Comments
Front naht tire is flat and needs replacement
WHEELS TIRES
Amount Totals
Total Labor: $29.95
Total Parts: $ 1,100.21
Gas, Oil, Lube + Sublet + Misc: $ 7.75
Total Labor: $ 29.95
Total Parts: $ 1,100.21
Gas. Oil, Lube + Sublet + Misc: $ 7.75
•OEM means Original Equipment Manufacturer (factory) Parts | ** All parts are New unless specified otherwise. 06/15/2023 9:16 PM ~~ Thank you for your business~~
Mercedes-Benz
DOWNTOWN LA MOTORS
Mercedes-Benz of Los Angeles Repair Order #: 298438
1801 South Figueroa Street Tag #: T978
Los Angeles. California, 90015, US Advisor: Yolanda Dunn Phone: 2137488951 Advisor No. #: 268825
http://www.los-angeles.mercedesdealer.com Order Open Date: 2023-06-07 Sales Tax: $ 104.52
Shop Supplies: $ 0.00
Customer Total: $ 1,242.43
Terms and Acceptance
Customer acknowledges approval of work described in this Repair Order Summary. Any Warranties on the product sold herein are those made by the manufacturer. The seller hereby expressly disclaims all warranties, either express including any implied warranty of merchantability or fitness for a particular purpose. and neither assumes nor authorizes any other person to assume for it any liability in connection with the sale of said products.
Please look for a survey on your service experience. The manufactures survey will be sent to you by email. If you are not sure if your current email address is on file please check with your service advisor. X.
We're working hard to make customers for life!
07/31/23
Image from my dash came with "as well as X40
time of datle as well as
visible potholes.
nexar
2023-06-06 16:46:38
07/31/23
Area where potholes
Mail body: Car damaged my venicle.
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