Item 11 - Claim for Damages-==T*,-,,AGEN
DA REPORT o�
Q
CITY OF POWA
This report is.included.on. the Consent Calendar. There will be no separate discussion of the
report prior to approval. by the City Council unless members of the Council, staff or public ��c ��..,.. «• "S�1
request it to be removed from•the Consent Calendar and discussed separately. if you.wish to THE coy
have this report p pulled for discussion, please fill out a slip indicating, the report number
and give it to the City Clerk prior to the beginning of the: City Council meeting:
TO::
Honorable Mayor and Members of the City Council
FROM., Jamea L. Bowersox, City Manage
�
INITIATED BY: Kay D. Jimno, Director of Administrative services.��
DATE: January 14, 1986
SUBJECT: Claim for Damages
Karen DeScisciolo
1 of 4
JAN I. jr 198 1-1 ;:-7- t'lt
CITY OF PCWAY A
CLAIM AGAINST THECITY OF PGtn7AY
y via
Received b � � �'. �; / � • .
s
U.S. S, Mas.l
NOV 1 �3 Clerk's Time. S }
Inter -Office Mail
1 85 �,p
Over the Center D, ,�;r• ..
A claim must be filers, with the City Clerk of the City of Poway within 1Q0 days,
ays after
which the incident or event occurred. Be sure your claim is. against: the City of
Poway,. not another public entity. Where space, is insufficient
Please-, use a,dditanal
paper and identify information by paragraph number Completed, claimsmust. be mailed.
or delivered to the City Clerk, The City of Poway, 13325 Civic Center Drive, may,
CA. 92064 (P.O. Box 785).
TO THE. SJNORABLE MAYOR AND CITY CCUNCILF THE CITY OF POWAY CALIFORNIA
The; undersi undersigned res -
g respectfully submits the following claim and. information relative: to
damage to persons and/or pers=ial property.
i
1. NAME OF CLAIM0T l S
e
a. ADDRESS OF CLAIKw
b. PH)NE N0. c. DATEL, OF BIRTH
d.. SoczAL Snc1jR1Ty No. , DRIVER. tS LIC. Na.
2. Naive, telephone and
p post. office address to which claimant. desires notices, to be: t.{
sent, if other than above
3.. Occurrence:or event.from which the claim arises:
a.. DATE f S b. TIME` 30 A 1, c. PLACE (exact and specific location
rl }
d. Fbw and under what circumstances: did damage or injury occur? Specify the
particular occurrence:,, event, act or emission you. claim caused the injury or,
dam3 s io a
a (uadditl paper if necessaryl.
2S% C. k CJ ep_ t
4L4V,--�Q e�s 'I ; s A. hQ-
4;
m W n C� -Euro ,v10 n elZ� �d, � r)S. �r'A c� Q- I RPM(
e. what particular action by the Ci y, or its e�loyees;,1 caused the alleged
damage or injury?'
JAN 14 1986 t T
2 of 4
4. Give a descripti of the injury, property damag loss, so far as is known at
the time of this If there were no in 'urie'
-ate "no injuries.
r �i'
5 Give name(s) of the City employee(z) causing the damage or injury
6 Name and address of any -other person injured:
7. Name and address of: the owner of any damaged property:
J�An
S tSCvlo {
8.. Damages; claimed: r10 e�22MI,nQd AS �0
a.- Amount claimed as of this date:
b. 'Estimated amount: of future costs
c.. Total amount claimed.
d. his for
computationof amounts clawed (include copies of all bills
invoices, estimates., etc.,): su. b M -H e6
9.. Names and addresses of all witnesses, hospitals:, doctors,. etc.
a.
b..
d.
10. An additional information that ;might be he �pful in nsidert� ,th claim:
t. e 0 PCIS; - 1 CSL' O 1\ 1 3> 2.. - i' 5.
�� A CIS�2 1 � � r � � V 1 � l l � 0� � C � N � i' C;,(J . �•
n '
,`
WARNING:. T IS A CRIMINAL OFFENSE' TO FILE A FALSE CLAIZ41 (Penal. Code. §72; Insurance
Code §556.1)
I have read the matters and statements: made in the above claim and.I'know the same to ,
be true of my own knowledge, except as. to those matters stated upon information or
belief` as to: such ratters I believe the same to be true. I certify ande
r
penalty
of
perjury that.the foregoing is TRUE and CORRECT.
da .1�
Signed this - �-
4 � Y of r 19 �.�t'
office of the City Clerk,
Poway, California
Doai = No.
3 of 4
FILID
A N 14, `386 i i` r
THE. PLUMBS mAINVOICE
4140 Fairmount Ave., 13634 Midland Road lu o n,41 7
an Diego,- CA 92105'
S 9 Poway, CA 92064
200-8954 435-2523
.. .; San Diego:271-6399
COMPLETE PLUMBING HEATING SERVICE:
SALES - INSTALLATION.- ELECTRIC SEWER DRAIN' CLEANING!
Catifa LIC No. 359731' f
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-
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DATE
!
_ QUAN
DESCRIPTION
AMOUNT
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x
( •
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17
1
TOTAL
to the event it is za:ess:ry to enO^■gb: the asneiees at an attorney to collect any of the: sums; owned hereunder.
• it is agreed thatthe prevailing: party in any action at taw ®nate be entitled to recover reasonable attorney's tees.
14 days from billing date, unpaid invoices W11t. bg PAST DUE and Subject to t'h% char e.
� 9 �A� 1 �� 198fi
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� � T �. ?�:�
4 of 4 the above charges to be: correct. X
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