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 RECEIVED 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) ACT 28 2024 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. CITY CLERK DEPARTMENT 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)
Crown Poly, Inc. N/A
Home Address of Claimant City and State Home Telephone Number
N/A N/A
Business Address of Claimant City and State Business Telephone Number 5700 Bickett St. Huntington Park, CA 90255 323-585-5522 Give address to which you desire notices or communications to be sent regarding this claim:
5700 Bickett St. Huntington Park, CA 90255
How did DAMAGE or INJURY occur? Give full particulars.
Slauson Ave was closed for through traffic on Boyle Ave., an unknown tractor trailer did a U-Turn and hit a city tree on the sidewalk of Boyle Ave., the tree fell and damaged Crown Poly Inc. fence. Pictures attached.
When did DAMAGE or INJURY occur? Give full particulars, date, time of day, etc.:
September 10, 2024 at approximately at 7am.
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:
It was on the side of 5701 Boyle Ave. Vernon, CA 90058 on the sidewalk of Boyle Ave. between 54th St. and Slauson Ave.
What particular ACT or OMISSION do you claim causedthe injury ordamage? Give names of City employees, if any, causing the injury or damage, if known:
An unknown tractor trailer did a U-Turn becuase they couldn't pass due to the street closure on Slauson Ave. and hit the city tree and caused it to fall over and damage Crown Poly Inc.'s fence.
What DAMAGE or INJURIES do you claim resulted? Give full extent of injuries or damages claimed:
Crown Poly, Inc. fence was bent and damaged. Pictures attached.
What AMOUNT do you claim of each item of injury or damage as of date of presentation of this claim, giving basis of computation:
Fence damage - $980.00. Invoice attached.
Give ESTIMATED AMOUNT as far as known you claim on account of each item of prospective injury or damage, giving basis of computation:
Fence damage - $980.00. Invoice attached.
Were you insured at the time of the incident? If so, provide name of insurance company, policy numbers and amount of insurance payments received:
N/A
Expenditures made on account of accident or Injury: (Date - Item) (Amount) Fence repairs, invoice attached. $980.00
Name and address of Witnesses, Doctors and Hospitals:
N/A
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. rehicle 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
7AT7,
FOR OTHER ACCIDENTS
CURB/
Boyle Ave.
CURB,
PARKWAY
54th St. SIDEWALK
Slauson
5701 Boyle Ave. Ave.
Vernon, CA 90058
yearnier damenalty of perjury, thatanature of Caiman or pursing ag on tach behats, is true and correct.
Signature of Claimant or person filing on his/her behalf, giving Catherine Browne relationship to Claimant: Crown Payin 10/16/24 General
Manager
NOTE: ALL CLAIMANTS MAY BE REQUESTED TO BE EXAMINED AS TO THEIR CLAIM UI DER 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) Rev. 8/4/16
Arrow Steel Fence, Inc.
Mailing Address: 3615 E. 8th Street
Los Angeles, Ca. 90023
Ph. (323) 269-4130
[email protected]
INVOICE
9/17/2024
Invoice No. 324583 Bonded & Insured
PO # 70081
Vendor: V11250
Crown Poly
5700 Beckett St.
Huntington Park, Ca. 90255
Tel: (323)585-5522
Location: 5701 Boyle Ave.
Description: Damage to One Iron Fence Panel
1. Replace One 90" X 70" Iron "Apache" Panel.
/" Sq. Pickets, 1-1/2" Top & bottom rails
2. Color: Black
Materials & Labor, Cost: $ 980.00
Completed: October 15, 2024
PO # 70081
Sincerely,
Jaime Villasenor - President
D.L. 323.440-2315