Anton Tumas
RECEIVED
AUG 2 2 2023
CITY CLERK'S OFFICE
To whom it may concern. Please find attached my claim to the City of Vernon for pothole damage to my vehicle. I provided the supporting documentation to the best of my abilities. Please do not hesitate to contact me for any additional information, email is the easiest way to reach me.
Thank you for your assistance with this matter.
Anton Tumas
August 17, 2023
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.
4. See page 2 for diagram upon which to locate place of accident
5. This claim form must be signed on page 2 at bottom.
6. 5. Cach must be fled wis, ily Clerk: (go. Code Sec. 915, SIN EACH SHEET.
TO: CITY OF VERNON CITY COUNCIL
Name of Claimant ze of Claimant (if natural person)
Anton Tumas
Home Address of Claimant City and State Home Telephone Number Business Address of Claimant City and State Business Telephone Number 1700 Nadeau Street, Unit 19. Los Angeles, CA 90001 1(818) 577-8624 Give address to which vou desire notices or communications to be sent regarding this claim:
How did DAMAGE or INJURY occur? Give full particulars.
I left my work and was driving home around 9pm, when I ran over a very large pothole on the road. This pothole resulted in damaged to my wheel, which required to be repaired and refinished due to significant damage it suffered.
When did DAMAGE or INJURY occur? Give full particulars, date, time of day, etc.:
March 2, 2023 at around 5:30pm. The address was 5700 Holmes Avenue, Vernon, CA 90058.
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:
I am attaching a map of the pothole, marked with a red circle.
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:
Street surface is in very poor condition, and is in need of repair. The pothole is more than 10" deep, and driving over it resulted in damage to the wheel.
What DAMAGE or INJURIES do you claim resulted? Give full extent of injuries or damages claimed:
Wheel bent and scratched. Wheel was not driveable until repairs were completed.
What AMOUNT do you claim of each item of injury or damage as of date of presentation of this claim, giving basis of computation:
$360 total: $260 for repair of the wheel, and time off work (I had to take half the day off to have the wheel repaired). Invoice from the tire shop is attached to this letter.
Give ESTIMATED AMOUNT as faras known you claim on account of each item of prospective injury ordamage, giving basis of computation:
$360 as above.
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, Geico. No claim was made. Policy # 4615324805
Expenditures made on account of accident or Injury: (Date - Item) (Amount) $260 for wheel repairs to Barkley Tire
Name and address of Witnesses, Doctors and Hospitals:
None
READCAREFULLY
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.
NOTE: if diagrams do not fit the situation, attach hereto a proper diagram signed by claimant.
FOR AUTOMOBILE ACCIDENTS
FOR OTHER ACCIDENTS
cURB/
CURB Y
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 relationship to Claimant:
m
OTE: ALL CLAIMANTS MAY BE REQUESTED TO BE EXAMINED AS TO THEIR CLAIM UNDER OATH. PRESENTATION OF A FALSE CLAIM IS A FELONY (CA N. CODE SEC. 72). CLAIMS MUST BE FILEDWITH CITY CLERK (GOV.CODE SEC 915a) STATE LAW PROVIDES THAT IF YOU ARE NOT NOTIFIED OF AN 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) Rev. 864/16
Barkley Tire & Services
900 S San Fernando Bivd
Burbank, CA 91502
BARKLEY TIRE AND 818-722-3366
WC SERVICE
Dal 900 S SAN FERNANDO RD : 1-2 Admin / 1-13 LAURA
In f BURBANK, CA 915021535
Contact:
2066737418 ****WORK ORDER****
Soli Cashier: SIYUAN DING Unit #:
Ante hip To:
21 Mar 2023 1:05:31P Vehicle: 12 BMW X5
107:
License: SUBTRCT
Suiti Transaction 101890
Los Mileage: In: 0 Out: 0
Mail: [email protected] Vin#: 5UXZW0C59CL669575
1 Manual Transaction $260.00 PO#:
OTY Desertion Pat FE Total
$260.00 260.00
Total
RIGH
CREDIT CARD SALE $260.00
VISA 6380
Retain this copy for statement
validation
21-Mar-2023 1:05:46P
$260.00 | Method: EMV
Visa Credit XXXXXXXXXXXX6380
ANTON TUMAS
Reference ID: 308000518270
Auth ID: 021359
MID: ***********7911
AID: A0000000031010
SIGNATURE VERIFIED
Online: https://clover.com/p
/XPGFYVWE2ACYP
Clover ID: 3M3DCKJT1G6YB
Payment XPGFYVWE2ACYP
Clover Privacy Pollcy
https://clover.com/privacy
Parts: 225.00
Labor: 35.00
Subtotal: 260.00
Sales Tax: 0.00
Signature
Total: $260.00
BYSKELA
Barkley Tire & Services
900 S San Fernando Blvd
Burbank, CA 91502
818-722-3366
WO # 1-17362 Page 1 of 1
Date 03/07/23 Emp: 1-2 Admin / 1-13 LAURA
In Mar 07, 2023 9:42 AM Contact:
****WORK ORDER****
Sold To: Ship To: Unit #:
Vehicle:
License:
Mileage:
Los Angeles CA 90230-4933 Vin#:
Cell Phone: 818-577-8624 E-Mail: [email protected] PO#:
(OrY FET Tolal
WRR WHEEL REG 1.00 WHEEL REPAIR 225.00 35.00 0,00 260.00
RIGHT REAR
Parts: 225.00
Labor: 35.00
Subtotal: 260.00
Sales Tax: 0.00
Signature: Total: $260.00
5529
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Google
Holmes AV
5700 S
5N95
Anton Tumas LOS ANGELES CA 90
38 AUG 2023 PM 18
FOREVER / USA FOREVER / US.
VERNON CITY CLERK
4305 S SANTA FE AVENUE
VERNON, CA
90058
90058-171405