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) RECEIVED
3. See page 2 for diagram upon which to locate place of accident
5. This claim form must be signed on page 2 at bottom. JUN 25 2025
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)
CITY CLERK'S OFFICE
TO: CITY OF VERNON CITY COUNCIL
Name of Claimant Age of Claimant (If natural person)
Alejandro Savedra 57
Home Address of Claimant oliv 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:
SAME AS ABOVE
How did DAMAGE or INJURY occur? Give full particulars.
IWAS EXiTiNG THE TOWY SOUTH BOUnD AFTER ExTiNg
mu vehiclenfall into a Huge Pot Hole. FRant BumpER Got
When did DAMAGE or INJURY occur? Give full particulars, date, time of day, etc.
Incideut happened EN VERNON ET ONS MA 1842 AT 12:00 pm
WAS OBSERVED FixeD oN June 134h 2025.
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:
CiTY Of VERNO ATLANTiC BLUD. T10 EXiT (SOUTH) SEE PIS
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:
THERE WERE SEVERAL POT HOlES oN
SEE BIN GETIMATE RADIATOR WAS BOSTED AND PEPAIRED
(THiN DAYS) (Cost d1242.81)
What AMOUNT do you claim of each item of injury or damage as of date of presentation ofthis claim, giving basisof computation: Incident MAy 18tu
SEE BMW ESTIMATE
REPAIRS TO STREETOBSERVED TUMe
Give ESTIMATED AMOUNT as far asknown you claim on account of each item of prospective injury or damage, giving basis of computation:
SEE BMW ESTIMATE SEE PICS)
Were you insured at the time of the incident? If so, provide name of insurance company, policy numbers and amount of insurance payments received:
No InVoRy To PERSON
Expenditures made on account of accident or Injury: (Date - Item) (Amount) ADIATOR # 1242,81
Name and address of Witnesses, Doctors and Hospitals:
None: Pies anly Pot Holes WERE FiRED AFTER
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. f City Vehicle was Involved, designate by letter "A" location of City vehicle when you first saw it, and by "B" location of yoursel r your vehicle when you first saw City vehicle; location of City vehicle at time of accident by "A-1" and location of yourself or you 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
UJWUL
/ ^
FOR OTHER ACCIDENTS
CURB/
city of ERNON BUAC
CURB
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:
Alejandre saveder 1013-25
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) BMW of Downtown Los Angeles CCRC Workfile ID: 58238315
State EPA: CAL 00038798
MINI 6000 South Alameda St., Huntington Park, CA BAR: ARD00274988 90255
Phone: (323) 277-4230
DOWNTOWN LOS ANGELES
Estimate
RO Number:
Customer: Insurance: Adjuster: Estimator: LUIS HERNANDEZ Savedra, Alejandro CUSTOMER PAY Phone: Create Date: 6/12/2025 Claim:
Loss Date:
(323) 849-9900 Deductible:
2008 BMW 3 Series 328i RWD SULEV 2D CPE 6-3.0L Gasoline MPI WHITE VIN: Interior Color: GRAY Mileage In: 141,058 Vehicle Out:
License: Exterior Color: WHITE Mileage Out:
State: CA Production Date: 5/2008 Condition: Job #:
Line Ver Operation Description Qty Extended Part Labor Type Paint Price$ Type
1 E01 FRONT BUMPER & GRILLE
E01 Overhaul O/H bumper assy OEM 2.6 Body
3 E01 Remove/Replace Bumper cover 1 913.72T OEM 0.0 Body 3.0 4 E01 Add for Clear Coat 1.2
E01 Remove/Replace Screen Inner 328i, 328xi, 335xi 69.55T OEM 0.0 Body E01 Remove/Replace RT Screen Outer 328i, 328xi, 335xi 1 63.76T OEM 0.0 Body E01 Remove/Replace LT Screen Outer 328i, 328xi, 335xi 1 63.76T OEM 0.0 Body 8 E01 Remove/Replace Tow eye cap 1 30.00T OEM 0.0 Body 0.2 9 E01 Add for Clear Coat 0.1
10 E01 Remove/Replace RT Guide insert 15.22T OEM 0.0 Body - -
11 E01 Remove/Replace LT Guide insert 15.33T 0.0 Body
12 E01 Remove/Replace RT Guide 1 33.08T OEM 0.0 Body
13 E01 Remove/Replace LT Guide 1 33.08T OEM 0.0 Body
14 E01 Remove/Install RT Grille 0.0 Body
15 E01 Remove/Install LT Grille 0.0 Body
16 E01 Remove/Replace RT Reflector 1 35.26T OEM 0.0 Body 17 E01 Remove/Replace LT Reflector 35.26T OEM 0.0 Body
18 E01 FENDER
19 E01 Remove/Replace RT Liner extension w/o M3 106.68T OEM 0.4 Body 20 E01 Remove/Replace LT Liner extension w/o M3 1 106.68T OEM 0.4 Body 21 E01 Remove/Replace RT Lower deflector 1 24.41T OEM 0.1 Body 22 E01 Remove/Replace LT Lower defector 1 24.41T OEM 0.1 Body 23 E01 Remove/Replace RT Lower cover w/M Package 83.60T OEM 24 E01 Remove/Replace LT Lower cover w/M Package 83.60T OEM 25 E01 FRONT SUSPENSION
26 E01 Remove/Replace Wheel alignment align four wheels OEM 2.0 Mech 6/12/2025 1:37:23 PM Page 1
Estimate
RO Number:
2008 BMW 3 Series 328i RWD SULEV 2D CPE 6-3.OL Gasoline MPI WHITE 27 E01 VEHICLE DIAGNOSTICS
28 E01 Repair Pre-repair scan 0.5 Mech
29 E01 Repair Post-repair scan 0.5 Mech
30 E01 MISCELLANEOUS OPERATIONS
31 E01 D&R wiring harness 0.5 Body
32 E01 Repair Color sand and buff 0.5 Body
33 E01 Color tint / color match 1 5.00T Other 0.5 Body
34 E01 Remove/Replace Flex Additive 1 8.00T OEM 0.2 Body Estimate Totals Discount $ Markup$ Rate $ Total Hours Total $ Parts 1,750.40
Labor, Body 95.00 5.3 503.50
Labor, Refinish 95.00 4.5 427.50
Labor, Mechanical 265.00 3.0 795.00
Material, Paint 62.00 4.5 279.00
Subtotal 3,755.40
Sales Tax
Grand Total
Net Total
Estimate Version
Original
Insurance Total $: 0.00
Received from Insurance $:
Balance due from Insurance $:
Customer Total $: 3,968.49
Received from Customer $: 0.00
Balance due from Customer $: 3,968.49
T = Taxable Item, RPD = Related Prior Damage, AA = Appearance Allowance, UPD = Unrelated Prior Damage, PDR = Paintless Dent Repair, A/M = Aftermarket, Rechr = Rechromed, Reman = Remanufactured, OEM = New Original Equipment Manufacturer, Recor = Re-cored, RECOND = Reconditioned, LKQ = Like Kind Quality or Used, Diag = Diagnostic, Elec = Electrical, Mech = Mechanical, Ref = Refinish, Struc = Structural
6/12/20251:37:23 PM Page 2
BMW of Downtown Los Angeles
6333 S Alameda St
LOS ANGELES, CA 90001
Phone: (323) 583-1901
RETURN/REFUND POLICY: ALL RETURNS MUST BE ACCOMPANIED BY THIS INVOICE AND ARE SUBJECT TO A 20% HANDLING CHARGE. RETURNED ITEMS MUST BE IN THE ORIGINAL UNOPENED BOX OR CONTAINER. PLEASE NOTE THAT THE DEALERSHIP WILL NOT ACCEPT RETURNS OR MAKE REFUNDS AFTER 10 DAYS. NO REFUNDS OR RETURNS ON SPECIAL ORDER PARTS OR ELECTRICAL PARTS.
THE ENTIRE RISK AS TO THE QUALITY AND PERFORMANCES OF THE VEHICLE AND PARTS AND ACCESSORIES IS WITH THE CUSTOMER AND, IF APPLICABLE, THE MANUFACTURER. IF THE VEHICLE OR ANY INSTALLED PARTS OR ACCESSORIES SHOULD PROVE DEFECTIVE FOLLOWING THEIR PURCHASE, THE CUSTOMER AND POSSIBLY THE MANUFACTURER AND NOT THE DEALERSHIP ASSUME THE ENTIRE COST OF ANY NECESSARY SERVICING OR REPAIR.
SILENCE FROM DEALERSHIP AN CONSEQUENTAL DAMAGES, DAMAGES TO PROPERTY. DAMAGES FOR LOSS OF USE. LOSS OF TIME, LOSS OF PROFITS OR INCOME, OR ANY OTHER INCIDENTAL DAMAGES.
DATE ENTERED YOUR ORDER NO. DATE SHIPPED INVOICE DATE INVOICE 12 JUN 25 P120129 12 JUN 25 NUMBER 012690 13:10
* *QUOTE**
ACCOUNT NO. 1111 - I c PAGE 1 OF 1
RETAIL
SHIP VIA SLSM. F.O.B. POINT
TERMS
453 CASH LOS ANGELES CA
PART NO. DESCRIPTION LIST NET AMOUNT
17-11-7-537-292 RADIATOR: UB131 1242. 871242.87 1,242.87 **** INVOICE QUOTE DO NOT PAY ****
already Installed. PARTS 1,242.87
SUBLET
was leak ina FREIGHT 0.00
SALES TAX 130.50
CUSTOMER'S SIGNATURE METHOD OF PYMT
TOTAL $1,373.37
NOTICE TO CONSUMER: PLEASE READ IMPORTANT INFORMATION ON REVERSE SIDE.
DealerCAP 2023 COK Global, LL 108/39,PARD9 INVOICE 1LP - PI3C1 - "AS-IS* - CALIFORNIA - 9696592
CUSTOMER COPY
ALL PARTS PROVIDED AS IS BY DEALERSHIP
A WARNING: Operating, servicing and maintaining a passenger vehicle or off-road vehicle can expose you to chemicals including engine exhaust, carbon monoxide, phthalates, and lead, which are known to the State of California to cause cancer and birth defects or other reproductive harm. To minimize exposure, avoid breathing exhaust, do not idle the engine except as necessary, service your vehicle in a well-ventilated area, and wear gloves or wash your hands frequently when servicing your vehicle. For more information go to www.P65Warnings.ca.gov/passenger-vehicle.
A WARNING: Breathing the air in a vehicle repair facility or skin contact with petroleum products can expose you to chemicals including benzene, motor vehicle exhaust, and carbon monoxide, which are known to the State of California to cause cancer and birth defects or other reproductive harm. Do not stay in an area where vehicles are repaired or serviced longer than necessary. For more information go to www.P65Warnings.ca.gov/vehicle-repair.
Laur ' let dae aton is reamed a no time ot priso un so daya are long with his dads.
BMW of Downtown Los Angeles
6333 S Alameda St
LOS ANGELES, CA 90001
Phone: (323) 583-1901
IF THE VEHICLE OR ANY INSTALLED PARTS OR ACCESSORIES SHOULD PROVE DEFECTIVE FOLLOWING THEIR PURCHASE, THE
CUSTOMER AND POSSIBLY THE MANUFACTURER AND NOT
TIME, LOSS OF PROFITS OR INCOME, OR ANY OTHER INCIDENTAL DAMAGES.
DATE ENTERED YOUR ORDER NO. DATE SHIPPED INVOICE DATE
INVOICE
12 JUN 25 P120129 12 JUN 25 NUMBER 012691 13:10
**QUOTE* *
no ACCOUNT NO. 1111 PAGE 1 OF 1
P
RETAIL
SHIP VIA SLSM. TERMS F.O.B. POINT
453 CASH LOS ANGELES CA
PART NO DESCRIPTION LIST NET AMOUNT
51-11-7-181-308 TRIM COVE 1075.821075.82 1,075.82
* * * * ****
I N VOICE QUOTE DO NOT PAY
PARTS 1,075.82
SUBLET
FREIGHT 0.00
SALES TAX 112.96
CUSTOMER'S SIGNATURE METHOD OF PYT
X TOTAL $1, 188. 78|
NOTICE TO CONSUMER: PLEASE READ IMPORTANT INFORMATION ON REVERSE SIDE.
DealerAP 2023 CO Global, LL 108/25 PAD NOICE 1UP. PI301 . "AS-IS* • CAUFORNA 9596592
CUSTOMER COPY
ALL PARTS PROVIDED AS IS BY DEALERSHIP
A WARNING: Operating, servicing and maintaining a passenger vehicle or off-road vehicle can expose you to chemicals Longine order as nectary, here our ena in wal on and are on or over or a or an frequently when servicing your vehicle. For more information go to www.P65Warnings.ca.gov/passenger-vehicle.
A WARNING: Breathing the air in a vehicle repair facility or skin contact with petroleum products can expose you tc chemicals including benzene, motor vehicle exhaust, and carbon monoxide, which are known to the State of California to cause cancer and birth defects or other reproductive harm. Do not stay in an area where vehicles are repaired o serviced longer than necessary. For more information go to www.P65Warnings.ca.gov/vehicle-repair DealerCAP 2023 CDK Global, LLC (12/23) Parts Only - "AS-IS Backor" - CALIFORNIA - 8965022 * 6/17/25; 1:26 PM Photo - Google Photos
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