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 filed not later than six (6) months after the occurrence. (Gov. Code Sec. 9112 JUL 21 2025
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. Reedene for agram inn CITY CLERK DEPARTMENT
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. 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)
Larry Harrow
Home Address of Claimant City and State THome Telephone Number Business Address of Claimant City and State Business Telephone Number 323-887-9500
Give address to which you desire notices or communications to be sent regarding this claim:
How did DAMAGE or INJURY occur? Give full particulars.
Broken sewer pipe.
When did DAMAGE or INJURY occur? Give full particulars, date, time of day, etc.:
3/18/2025
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:
4720 District Bivd. HP Tires building. Restroom sewers overflowing. Restroom walls sustained water/sewer damage.
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:
Gas line installed under the sewer line caused damage to the sewer line.
What DAMAGE or INJURIES do you claim resulted? Give full extent of injuries or damages claimed:
ost of initial plumbing calls. Cost to determine the issue. Cost to tear up the public roadway and determine fault. Cost 1 epair of the sewer line under the public roadway. Cost of excavation and asphalt replacement. Cost to fix damages to 472 District Blvd. including damages to restroom. Cost to rent porta-potty while repairs were being made.
What AMOUNT do you claim of each item of injury or damage as of date of presentation of this claim, giving basis of $900 for initial plumber. $49, 757 for excavation, sewer line repair under public roadway and asphalt replacement. $900 for drywall repair and paint. Total-$51,557 Basot computation. UNT as far asknown you claim on account of each item of prospective injury or damage, gwing Were you insured at the time of the incident? If so, provide name of insurance company, policy numbers and amount of insurance payments received:
None
Expenditures made on account of accident or Injury: (Date - Item) (Amount) Name and address of Witnesses, Doctors and Hospitals:
READCAREFULLY
of accell by in daby shace foule num lies or dance sire, reing North, East South, and West. indicate place NOTE If diagrams do not fit the situation, attach hereto a proper diagram signed by claimant.
FOR AUTOMOBILE ACCIDENTS
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FOR OTHER ACCIDENTS
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I declare, under penalty of perjury, that the for going, including any attachments, is true and correct.
Signature of Claimant or person filing on his/her behalf, giving Date Typed/Printed Name:
Larry Harrow 7/17/25
EN. 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 VOTE: ALL CLAIMANTS MAY BE REQUESTED TO BE EXAMINED AS TO THEIR CLAIM UNDER OATH. PRESENTATION OF A FALSE CLAIM IS A FELONY (CAL 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 Shelley Ledesma
From: Valdez, Javier < [email protected]>
Sent: Wednesday, April 16, 2025 5:06 PM
To: Larry Harrow
Cc: Shelley Ledesma
Subject: RE: 4720 District Bl
Hi Larry,
One more thing: please provide invoices or receipts for the actual work to review.
Thank you,
Javier Valdez
Risk Manager | Finance Department
O: 323.583.8811 x825 | M: 323.513.8088 | [email protected] www.cityofvernon.org | 4305 Santa Fe Ave | Vernon, CA 90058 Monday - Thursday | 7:00 am - 5:30 pm
-----Original Message-----
From: Valdez, Javier < [email protected]>
Sent: Wednesday, April 16, 2025 3:40 PM
To: 'Larry Harrow'
Cc: Shelley Ledesma
Subject: RE: 4720 District Bl
Hi Larry,
The link below will take you to the Claim for Damages form, for you to complete and return to the City Clerk's office. https://www.cityofvernon.org/how-do-i/fill-out-a/claim-form Please ensure the form includes sufficient details, and attach the received quotes, the contractor's repair proposal, photos, and any correspondence with City staff.
Let me know if you have any questions.
Thank you,
Risk Manager | Finance Department
O: 323.583.8811 x825 | M: 323.513.8088 | [email protected] www.cityofvernon.org | 4305 Santa Fe Ave | Vernon, CA 90058 Monday - Thursday | 7:00 am - 5:30 pm
1 -----Original Message-....
From: Larry Harrowl
Sent: Wednesday, April 16, 2025 7:54 AM
To: Valdez, Javier <[email protected]>
Cc: Shelley Ledesma
Subject: 4720 District Bl
Good morning
I'm Larry Harrow the owner of 4729 District Bl. We have an issue that I'd like to speak to you about. My sewer pipe has been broken by a gas line installation. I need to
find out the procedure for me to get reimbursed for my costs incurred and repair the pipe.
Please contact me asap.
Thank you
Larry Harrow
Emaill
Sent from my iPhone
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2 MARIO'S PLUMBING
4/28/25
4720 District
Invoice #4720-01
On 3/18/25
We were called out for sewage overflowing from toilets at bathroom.
At this time we had to lift up toilet to be able to run roto rooter through toilet closet bend.
We where able to clear it.
Ran 120 foot cable.
On 3/21/25
We came back out for same reason.
Lifted up toilet to clear.
Ran 100 foot cable.
On 3/25/25
At this time we return for a third time to hydro jetted out line out to street again,and run camera to scope out entire run to street.
Hydro jetted line at 3000 psi.
Total cost for parts and labor $900.00
Thank you for your business
Please make payable to
Marios Plumbing Services
CL#1076881
213 842-5174
Mario's Plumbing, Inc. | Serving all of Greater Los Angeles | 213.842.5174 raccift# 1 1fg
Craftsman Sewers
P.O. Box 128
San Dimas, CA 91773 US
[email protected]
Receipt
Date: 04/23/2025
BILL TO
Larry Harrow
4720 District Bivd.
Vernon, Ca 90058
Invoice Date Payment
Invoice Number
49757.00
1441 04/20/2025
$0.00
BALANCE DUE
RECEiPt # a 8P9S
INVOICE
Craftsman Sewers [email protected]
P.O. Box 128 +1 (626) 636-0087
San Dimas, CA 91773
106900
Bill to
Larry Harrow
4720 District Blvd.
Vemon, Ca 90058
Invoice details
Invoice no.: 1441
Invoice date: 04/20/2025
Due date: 04/21/2025
Amount
Product or service Description
Sewer line repair under public roadway. $22,000.00
Proposal
- Supply and manage all traffic control as needed in order to operate in the public roadway.
- Saw cut and remove asphalt as needed in order to
excavate and expose the failed section of the sewer line. - Shoring of the excavation is included.
- Splice, remove and replace the failed section of the sewer line with approved material and heavy-duty repair
couplings as required. This section of repair will be +/- 6' in length and will have a proper rock bedding unlaying the pipe as required.
- Place traffic rated steel plates over the excavation as needed daily while work takes place and city inspections are performed.
- Backfill the affected area as needed in order to restore full compaction to match the existing grade.
- Re-pave asphalt as needed in order to restore the
roadway to a smooth surface. (This does not include any beautification of the asphalt roadway that is larger than our excavation patch.
NOTES**
* 10yr warranty on all new material installed by contractor. * Contractor will obtain one public works permit. (City permit fees are not included and will be paid by the
property owner at the cost of issuance only.)
* Contractor will manage all inspections and record,
photograph all work as needed to figure out what has 4/20125 caused the damage to the sewer line. A recording of the sewer line will be done before and after the line is V #1104 repaired.
* Contractor will remove all debris created by this scope of work.
* Additional $1,500.00 to install a liner interior of the sewer dist. line to patch the failed section of the sewer line under the sidewalk area if the line is suitable for a patch.
dditional work required in order to change elevation c $21,000.00 Services Performed
kisting sewer lateral and gain proper clearance from C
of Vernon gas main.
Saw cut and remove asphalt as needed in order
cavate and splice/connect to the existing lateral ar
drop the elevation as needed.
- Extend excavation and grade as needed to move sewer
pipe below the existing gas main.
- Switch traffic control as needed in order to operate in the second lane of traffic and perform the exact same method of excavation in order to connect to the lateral at a lower point.
sphalt Replacement: Provide traffic control as needed $5,600.00 Services Performed
order to divert the flow of traffic for both lanes of trave - Saw cut and perform T-cut around excavation as needec for asphalt restoration.
- Repave the excavation trench as needed as one uniform patch.
Vernon Encroachment permit. $1,157.00
Permit Fee
Total $49,757.00
Overdue 04/21/2025
Craftsman Sewers [email protected]
P.O. Box 128 +1 (626) 636-0087
San Dimas, CA 91773
Bill to
Larry Harrow
4720 District Blvd.
Vernon, Ca 90058
Estimate details
Estimate no.: 1382
Estimate date: 03/30/2025
Product or service Description Amount
Proposal Sewer line repair under public roadway. $22,000.00 - Supply and manage all traffic control as needed in order to operate in the public roadway.
- Saw cut and remove asphalt as needed in order to
excavate and expose the failed section of the sewer line. - Splice, remove and replace the failed section of the sewer line with approved material and heavy-duty repair
couplings as required. This section of repair will be +/- 6' in length and will have a proper rock bedding unlaying the pipe as required.
- Place traffic rated steel plates over the excavation as needed daily while work takes place and city inspections are performed.
- Backfill the affected area as needed in order to restore full compaction to match the existing grade.
- Re-pave asphalt as needed in order to restore the
roadway to a smooth surface. (This does not include any beautification of the asphalt roadway that is larger than our excavation patch.
NOTES**
* 10yr warranty on all new material installed by contractor. * Contractor will obtain one public works permit. (City permit fees are not included.)
* Contractor will manage all inspections and record,
photograph all work as needed to figure out what has
caused the damage to the sewer line.
* Contractor will remove all debris created by this scope of work
* Additional $1,500.00 to install a liner interior of the sewer line to patch the failed section of the sewer line under the sidewalk area if the line is suitable for a patch.
Total $22,000.00
Accepted date Accepted by
Estimate #32619
Acosta & Sons Sewer Contractor CSLB#273035 DIR# PW-LR-1000368298, WBE & DBE #50259, SBE #4287
Sewer Lline Inspection with High Definition $2,880.00
1 X $2,880.00
6" Sewer Lateral Construction & Connection $27,000.00
20 X $1,350.00
Shoring Plans $1,200.00
1 X $1,200.00
TRAFFIC PLAN $650.00
1 X $650.00
TRAFFIC CONTROL $4,800.00
1 X $4,800.00
Encroachment Permit $9,630.00
1 X $9,630.00
Bonded Sewer Fee $5,000.00
1 X $5,000.00
Warranty $0.00
1 X $0.00
$0.00
Disclaimer
1 X $0.00
From: Acosta & Sons Sewer Contractor CSLB#273035 DIR# PW-LR-1000368298, WBE & DBE #50259, SBE #4287 Subject: Estimate 2039 from Acosta & Sons Sewers Contractors Date: March 25, 2025 at 12:37 PM
To: [email protected]
ACOSTA
Your estimate is ready!
Total Estimate
$51,160.00
or starting at /month with financing (36 mo)*
Review and accept
Pay VISA DISCOVER BANK
Dear Customer,
Below are your estimate details. To move forward with this estimate, please review and select Accept and Acosta & Sons Sewer Contractor CSLB#273035 DIR# PW-LR-1000368298, WBE & DBE #50259, SBE #4287 will reach out with next steps.
There are various payment methods available for you, you also have the option to pay this monthly.
Have a great day!
Utility Location and Responsibility Disclaimer $0.00
Disclaimer on Costs and Unforeseen Conditions $0.00
1 X $0.00
Total $51,160.00
or starting at /month with financing (36 mo)*
Acosta & Sons Sewer Contractor CSLB#273035 DIR# PW-LR-1000368298, WBE & DBE #50259, SBE #4287
[email protected]
* Personal loans made through Upgrade feature Annual Percentage Rates (APRs) of 8.49%-35.99%. All personal loans have a 1.85% to 9.99% origination fee, which is deducted from the loan proceeds. Lowest would total $12,293.46. The APRon your loan may be higher or lower and your loan offers may not have multiple term lengths available. Actual rate depends on credit score, credit usage history, loan term, and other factors. Late payments or subsequent charges and fees may increase the cost of your fixed rate loan. There is no fee or penalty for repaying a loan early. *Approval not guaranteed. Your loan terms will be determined based on your credit, income, and certain other information provided in your loan application. Not all applicants will qualify for the full amount.
Loan services offered through Credit Karma Offers, Inc. NMS ID# 1628077 | Licenses I NMLS Consumer Access. California Loans arranged pursuant to a California Financing Law License.
If you receive an email that seems fraudulent, please check with the business owner before paying, or you can forward the email to [email protected] so we can look into it. Read more at security.intuit.com.
INVOICE
DATE: TO: Larry Harrow
5/14/2025 4720 District LLC
INVOICE #
8451
CUSTOMER ID:
4720DistrictLLC
SALES REPRESENTATIVE JOB PAYMENT TERMS DUE DATE
NA - FG Repair & Paint Due on receipt 5/14/25
QTY DESCRIPTION LINE TOTAL
Repair lower 3 feet of drywall & paint water damaged area of bathroom walls due to toilet overflow 900.00
SUBTOTAL 900.00
SALES TAX
TOTAL 900.00
MAKE ALL CHECKS PAYABLE TO FG PAINTING
Thank you for your business!
FRANCISCO GARCIA 1645 S BERENDO ST | LOS ANGELES, CA 90006 RICER# 3 1Pg
ORIGIN ID IDYA
SHIP DATE 18JUL25
ACTWGT. 1.00 LB
CAD: 8214059/INET4535
BILL SENDER
OFFICE OF THE CITY CLERK
OFFICE OF THE CITY CLERK
4305 SOUTH SANTA FE AVENUE
VERNON CA 90058
(323) 887-9500 REF: LH SL
LIH SI
FedEx.
Express
EI
TUE - 22 JUL 5:00P
L201 8828 9827 2968 ** 2DAY **
Envelope
90058
CZ EMTA
CA-US LAX
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4305 5 SANTA FE AVE 4901 MUN 07/210702
429-3043 90058-1714-05
стр , LOS ANGELES,CA
SPPD 100 Y
882898272968
Align bottom of peel-and-stick airbill or pouch here.
Claim Form
How to File a Claim With the City of Vernon
Pursuant to the California Government Tort Claims Act (Government Code sections 810-996.6), a claim must be filed if you are seeking money or damages from the City or one of its employees. With very limited exceptions, no lawsuit for money damages may be brought against the City or its employees unless a written claim has been properly filed with the City. Claims for death, injury to person or to personal property must be presented to the City within (6) months from the date of loss (Government Code Section 911.2). Claims related to any other loss must be presented to the City no later than one (1) year from the date of loss (Government Code Section 911.2(a)).
Warning: This is not intended as legal advice. You should consult with an attorney to determine the time period for filing either a claim or a lawsuit.
The City of Vernon has a standard claim form that can be used for your convenience. This form must be filed in person, or by mail, directly with the Vernon City Clerk located at 4305 South Santa Fe Avenue, Vernon, CA 90058. The City will review, and where appropriate, take action on the claim. However, neither the City Attorney nor any other City official or employee can provide legal advice concerning the claim or litigation against the City.
Please print out the Claim Form, sign it, attach any supporting documentation (e.g. repair estimates, invoices, proof of payments, photos of damage, etc.) and either deliver it directly to the Office of the City Clerk or return it by mail to the Office of the City Clerk at the address set forth above.
• Claim Form