CLAIM FOR DAMAGES RESERVE FOR FILING STAMP
TO PERSON OR PROPERTY CLAIM No.
INSTRUCTIONS
RECEIVED
1. Claims for death, injury to person or to personal property must be tiled 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) APR 1 6 2024
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. CITY CLERK DEPARTMENT
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)
Anthony Alvarez Maywood CA 40 yrs
Home Address of Claimant City and State
Business Address of Claimant city and state Business Telenhone 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.
Pot hole, I was driving North East on Fruitland Street (roughly around 4975-4801 Fruitland Ave Vernon) it was dark out and hard to see when I suddendenly hit the pot hole and heard and felt a loud POP I then realized I had a flat tire because of striking the tire. I had to drive back home because my car was unable to be driven.
When did DAMAGE or INJURY occur? Give full particulars, date, time of day, etc.:
Febuary 10, 2024 around 8:00 p.m.
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:
emon) it was dark out and hard to see when I suddenderly hit the pot hole and heard and foll a loud POP I then realized I had a flat tire because of striking the tire. I had to drive back home because my car was unable to be driven.
measurements of landmark -33.9945938-118.1871830
What particular ACT or OMISSION do you claim caused the injury or damage? Give names of City employees, if any, causing the injury or damage, if known:
Extreme damage to tire and vehicle shocks.
What DAMAGE or INJURIES do you claim resulted? Give full extent of injuries or damages claimed:
Unplanned tire repair damage and vehicle shocks.
What AMOUNT do you claimof each item of injury or damage as of date of presentation of this claim, giving basis of computation:
The total amount of damages caused are $280.00 + $40.00 Give ESTIMATED AMOUNT as faras known you claim on account of each item of prospective injury or damage, giving basis of computation:
total amount of damages is $320.00
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 Insured, Connect Insurance policy #
Expenditures made on account of accident or Injury: (Date - Item) (Amount) total amount $320.00
Name and address of Witnesses, Doctors and Hospitals:
None
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.
NOTE:If diagrams do not fit the situation, attach hereto a proper diagram signed by claimant.
FOR AUTOMOBILE ACCIDENTS
7119,
FOR OTHER ACCIDENTS
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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:
Anthony Alvarez relationship to Claimant: 04/10/24
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 FILEDWITH 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) Rev. 8/4/16
008614
ED OTHERWISE Specialist in Japanese Cars
REMANUFACTURED
• Equpment Manufacturer) DATE
OPERATION
4-3-24
SPECIALISTS IN JAPANESE CARS SALE abricator
• TOYOTA 8738 Long Beach Bivd NISSAN TIME RECEIVED AM
8738 LONG HEACH BLYD PM Change Of
SOUTH CATE CA 90280 South Gate, CA 90280 CUSTOMER
[ESTIMATED AM Change Oi
323-567-1616 HONDA B.A.R. #AJ 201388
(323) 567-1616 Service
04/03/2024 11:44:22 WRITTEN BY Al Clean
Merchant ID: Change
•••9690 IN SHADED AREAS. TVW SSV101
Device ID: YEAR / MAKE Trans Ol
Terminai 0001 • CUSTOMER: PLEASE FILLIN ALL THE NEORMATIO carrosab PP01 2019 Joyot an
Credi l Sale: Am Anthony Alvarez
( ) Avalan Tourer Radioni
Transaction #: CELL Wheel Brge
Card Type: CITY STATE 2P Rotate
Yisa )
accounta Tres
0628 TERGINE SIZE CUSTOMER ORDER NO.
Entry: E-MAIL ADDRESS Lina 222 [Adiust •
Chip
RECOMMENDED SERVICE: VEHICLE
Amoun 1 USD$560. 00 LD. NO.
Parts and labor are warranted for 000 miles or morths, whichever comes 1st. Verver STAN: Thes warranty is limited to the work mentioned on this form only and is not transferable. Ventd CHECK FACILITY TO PERFORM ANY NEEDED INDICATES ARE NECESSARY 001 must be returmed to our workshop at customers expense, along with this invoice, to hones Auth Code: 42243D
Batch Number: warranty. No warranty on customer suppled parts.
AUTH/TK® WARRANTY IS VOID IN CASE OF MISUSE ANDIOR NEGLECT AMOUNT Kesponse: OPER. NO. REPAIR ORDER - LABOR INSTRUCTION
ACI Code:
TRANS ID: 584094677648250
PROCESS AS: CREDIT
Mode: Issuer
AID: #0000000031010
280°
TYR: 8000008000
customer Supplied parts
4-3-24 Replaced (6) spark plags- custome, suppled perta) 200
AY CHOOSE ANOTHER LI IRS OR ADJUSTMENTS THAT THE SA
Tre Pressures: LF @decine having my fire Pressure checked for the following reason: • PS DESCRIPTION AMOUNT Total Labor •I] RETAIN PARTS • DESTROY PARTS 560 0
anted beyond warranties a it has been checked in last 30 days. lt will be checked i next days. O No nitrogen gas avalable ENGINE OIL A Total Parts Pape clara turn No other warrantes are made excell EARDOWN ESTIMATE: I understand that my vehicle will be reassembled within days of the TOTAL PARTS TRANS. OIL B Sublet Repairs BY LAN VOI
harge (na do rol imbing) not to authoria til be mad ecommended, a diagnosie and handin SUBLET REPAIRS with the necessary material, and hereby grant you BRAKE FLUID I hereby authorize the abave repair services to be done Towing ployees, permission to operate the car, truck, scribed on streets, highways or runics hen is hereby acknowiedo st be hall respondent tered o GREASE Storage Days
damage to vehicle or articles left in venice in case of fire, theft, + other cause beyond your control. COOLANT the event legal action is necessary to enforce this contract, 1 wil natle attorney's fees and court costs. Hazardous Waste
ORIGINAL ESTIMATE PLEASE READ REVERSE SIDE DATE TIME
GAS Smog Certificate
Autonzo
REVISED ESTIMATES COST ADSTONALS
O PHONE DEMAL DATE
Authorized
• PERSON FAX TIME
REVISED REASON ADOPTIONAL S C TOTAL FLUIDS C Total Fluids
ESTIMATES COST
Authorized O PHONE DE-MAL DATE per day will be charged or •PERSON OFAX al vehicles left over 48 hours a de congle dan i won Sub Total TIME
I of an rease in the orpinal estated price TERMS: NO CHECKS Sales Tax B TOTAL SUBLET REPAIRS: SIONATURE X UNLESS PREVIOUS ARRANGEMENTS ARE MADE % AS Service Charge will be soplied 00
on any returned chack. TOTAL 4560