Item 16 - Rejection of Five (5) Claims for Damage Against City
AGENDA REPORT SUMMARY
TO: Honorable Mayor and Members of the City Council
FROM: James L. Bowersox, City Man~ . ,
INITIATED BY: Warren H. Shafer, Director of Administrative Services &
DATE: April 26, 2005
SUBJECT: Rejection of Five (5) Claims for Damage Against the City of Poway
ABSTRACT
Five claims for damage were received by the City of Poway. One claim is for personal injury, and
four claims are for property damage.
ENVIRONMENTAL REVIEW
This item is not subject to CEQA review.
FISCAL IMPACT
Unknown.
ADDITIONAL PUBLIC NOTIFICATION AND CORRESPONDENCE
None.
RECOMMENDATION
It is recommended that the City Council reject these claims.
ACTION
c:\data\agenda\claimsummary 4-26-05.doc
7/1/03
1 of 16
April 26, 2005 Item # '"
CITY OF POWA Y
AGENDA REPORT
This report is induded 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 request it to be removed from the Consent Calendar and discussed separately. If you wish to have this report 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:
FROM:
Honorable Mayor and Members~e City Council
James L. Bowersox, City Mana~
Warren H. Shafer, Director of Administrative service&
Peter Moote, Deputy Director of Administrative Seryices
Steven Salvati, Senior Management Analyst ~.s5
INITIATED BY:
DATE:
April 26, 2005
SUBJECT:
Rejection of Five (5) Claims Against the City of Poway
BACKGROUND
Claims against the City of Poway were received as follows:
1. Received from Bernice Senior on May 28,2004, for personal injury. The amount of the
claim is $100,000.00.
2. Received from Glen & Julie Seebruch on January 18, 2005, for damage to personal
property. The amount of the claim is $2877.38.
3. Received from David Cabral on January 20, 2005, for damage to personal property.
The amount of the claim is $2550.
4. Received from Jose Yakuta on March 1, 2005, for damage to personal property. The
amount of the claim is $813.23.
5. Received from Roy Habibi on March 4, 2005, for damage to real property. The amount
of the claim is not determined.
FINDINGS
The City's claims administrator has determined that the City holds no liability in these claims.
ENVIRONMENTAL REVIEW
This item is not subject not CEQA review.
2 of 16
April 26, 2005 Item #
110
Rejection of Claims
April 26, 2005
Page 2
FISCAL IMPACT
Unknown.
ADDITIONAL PUBLIC NOTIFICATION AND CORRESPONDENCE
None.
RECOMMENDATION
It is recommended that the City Council reject these claims.
Attachments: 1. Claim for Damage - Bernice Senior
2. Claim for Damage - Glen & Julie Seebruch
3. Claim for Damage - David Cabral
4. Claim for Damage - Jose Yakuta
5. Claim for Damage - Roy Habibi
c:\data\agenda\claimsreport4-26-05(S) .doc
3 of 16
April 26, 2005 Item #
7/1/03
110
City of Poway
[5) IE ~ IE ~ \YllE fRI
!Ill 2 8 MAY 2004 lW
CLAIM AGAINST THE CITY OF POWAY
AGEMENT
Received by <) +c-v~ ~,...,,\v~ ' via
U.S. Mall
Inter-OIIIce Man
Over the Coullter
./
N~ 5;';\e"
(,0-;-04-0'2.-'"
')~ 1'\1'",,--
A claim mulIt be ftIed wUh the CIIy C1e1tl or RIslc Manager 01 the City 01 Poway within 8 mot Ilha after which !he Incldent or event
occurred. Be sure your claim is against the CIty of Poway. not another public entity. Where spac:e Is Insufficient. please use
additlonal peper aflll identIIy inlonnallon by paragraph number. CQjI~ claims must be n1ilIed or delivered to The City of
Pow.y, 13325 CMc center Drive. Poway, CA ll2084 (p.O, Box 189). Atln: Rl~ Manager.
TO THE HONORABLE MAYOR AND CITY COUNCIL, THECIT'f OF POWAY. CALIFORNIA
Tho unclerslgried respectfullY aUbmllS the following Claim anll Information relatiVe to C1amage to persons and/or personal
property:
1. Name ofclalmanl Bernice Senior
e, Addresaofcl8lmant -'-
b; Pholl. NIT;
d. SocIal Security No.
c.1)ate1)f BIrth
.. Ol'lver's Lie. No.
None
2. N/Ime. telepllO/le and post oIIIce address 10 whlcI'I cIalmant desires notices to be sent II other than above:
Brian R. Riley, Law Offices of Brian R. Riley, 16476 Bernardo Center Dr.
~u1~~ IOu, ~an u~ego, ~8 ~~I~~
1'858) 487-5451
3. CXcUl'l'enCll or event fIom Wlllch the ofaim ari_
a.Date February 4,2004 b.T1me Approximately 8:30 p.m.
G. Place (8lClKlI andspedllc; ~) North sidewalk Metate Lane across the street from 12455
d. How llnd undaf what ctrcumetanees did dam8.ge or lnjwy 0CCUf1 Spec;ily the pattlculer OlllllJmtnCe, event. &d of omI881on
you otafm caUMd the Injury or dernage (use addIlIoneI JllIl*' II n.oessary).
The concrete is raised approximately one and three-quarter to two inches
which caused Bernice Senior to trip and fall onto the concrete and the
lighting in the area was insufficient.
e. Whal P8ttlculat $Otlon by the CIly. or iIlI employee8, Gaused !he allegeclllamage or Inll.lfY?
Failure to properly inspect. maintain and repair thedanqerous and
defective raised concrete condition as stated in 3Q. Failure to provide
adequate lighting.
4 of 16
Attachment 1
April 26, 2005 Item # 110
'''-'-''' .....
4. Give a description of the injury, property damage or lOss 80 far as is known at the time of the claim. If there were no Injuries.
state -No Injuries."
Injuries include but are not limited to fractured nose, cut lip and gum requiring stitches,
nerve aamage to tour tront teeth reqw.rlng root canal.s, l.eft knee paln, and headaChes.
5. Gille name(el of the City employee(s} causing the damage or injury;
Uriknown at this time.
6. Name and address of any other person injure<l:
N/A
7. Name and addren of the owner of any damaged property:
N/A
8. Damag81 claimed:
a. Amount claimecl as of this date $ 1 0 0 , 0 0 0 . 0 0
b. E8lImated amount of future costs: $ . unknown
$ 100,000.00
c. Total amoUl1t claimed:
d. Ba8ls-lor computation1lf amounts Claimed (inciudecopl8s of aft blIIs; invoices; fltimates. ete.)
Serious injuries, pain and suffering, medical expenses, mental trauma.
9. Names and .add_. of an witnesselI, hospitals, doclOrS. etc.
a. Terry Senior (husband)
b. Pomerado Hospital ER
Kaiser Permanente, Jonathan Yee, M.D., Clairemont Mesa
Richard Katnick, D.D.S., 7319 Clairemont Mesa Blvd., San Diego, 92111
c.
d.
10. Any additional information that might be helpful In eonslllering the claim:
WARNING: IT IS A CRIMINAl OFFENSE TO FILE A. FALSe CLAIMI (Penal Coda 572, Insurance Code 5 556,1)
I have read !he matt..... and atatemenls made in the above claim and I know !he .._ to be true 01 my own knowledgll. oxcept
as 10 ttl088 mallets stated upon information or belief as to such matters I believe the same to be true. I certify under penally of
perjury that the foregoing IS TAUE and CORRECT.
SignedlhlS~dayof ~A1 ,w-too~,at .. ) PoWWf/Jt
Claimant's Signature IS..~ ~
Office oflbe City Clerk
Poway, California
nn""'I""'~NT Nn
FILED
5 of 16
April 26, 2005 Item # I b
via
~
~
City of Poway
CLAIM AGAINST THE CITY OF POWAY
Received by Sk ~,Jt'~'
U.S. Mail
Inter-Office Mail
Over the Counter
18
te Stamp
jVrMJ f,'l.e.
Coq '-01(, D 1.(
s.e.(;\.r"~~
,/
CITY OF POWAY RISK MANAGEMENT
A claim must be filed with the City Clerk or Risk Manager of the City of Poway within 6 months 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
additional paper and identify information by paragraph number. Completed claims must be mailed or delivered to The City of
Poway. 13325 Civic Center Drive, Poway, CA 92064 (P.O. Box 789). Attn: Risk Manager.
TO THE HONORABLE MAYOR AND CITY COUNCIL, THE CITY OF POWAY, CALIFORNIA
The undersigned respectfully submits the following claim and information relative to damage to persons and/or personal
property:
1. Name of claimant
fJlefl
ct JuJ{ e~
,,'Sf" E:'" IorGLc:J,
a. Address of claimant
v
--,
. b Phone No. ~
d. Social Security No.
c nata of Birth
e. Driver's Lic. No.
"
2. Name, telephone and post office address to which claimant desires notices to be sent if other than above:
W/A-
3. Occurrence or event from which the claim arises:
a. Date Del'. 31, c1 aD<-/- b. Time U '. 00 pyY1
c. Place (exact and specific location) ~ \( '1 r ,. cl. j e K A . - "-\pll.r \k 1 aJ e r +ow e v
d. How and under what circumstances did damage or injury occur? Specify the particular occurrence, event, act of omission
you claim caused the injury or damage (use additional paper if necessary).
<!..J2(" d.+ta ('.h e:. ol
e. What particular action by the City, or its employees, caused the alleged damage or injury?
~ StiLi iJ\~ n{ re.+Q;ni1\3 \~()_J\ (1{)c\ ,~lll_jU-c1(d -Pe (1Ce~
II of 111
Attachment 2
April 26, 2005 Item #...l:!L.
4. Give a description of the injury, proper.. lamage or loss so far as is known at the tit
i'state "No Injuries."
, 6Do-okr ?~f
SLj.5 -fe fh
- ,~p a if flfhe. cI..
)f the claim. If there were no injuries,
~
5. Give name(s) of the City errployee(s) causing.the damage or injury:
nlet. ,.
6. Name and address of any other person injured:
n/CL
7. Name and address of the owner of any damaged property:
(lien <.\..:::rlJL\i e S eebrtA.(~J,
pol...:lC4-j ot ?-..O(Y4-- ~:, ~3
8. Damages claimed:
I
'J
a. Amount claimed as of this date
b. Estimated amount of future costs:
c. Total amount claimed:
$ ;<. <:r"" 3 f
$
$ ;2'P.", :~g
,
JLBasisJor computation otalIlouols..dairned.{ince copies of all biUs.invoices.-.estimates,~
,~p en 00 &<" 0( \ ('Iv DI C e.. (l Yi el P.s.\-; CY'Q.)-e
9. Names and addresses of all witnesses, hospitals, doctors, etc. IJI L
a.
b.
c.
d.
10. Any additional information that might be helpful in considering the claim:
l;OUJ f!.5 e(l close'
WARNING: IT IS A CRIMINAL OFFENSE TO FILE A FALSE CLAIM! (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 matters I believe the same to be true. I certify under penalty of
perjury that the foregoing is TRUE and CORRECT.
Signed this 1(,
day of .::::Y.; i1 '-.61 ~ /1
/7 ~ L. ~~ 4
...----" ---' . .,~ --
~
Z()D5
,1-8'" ,at
1 /~/ bh
,
Claimant's Signature
Office of the City Clerk
Poway, California
DOCUMEtl{TJft6
FILED
AI." iI 26, 2665 Item # ~
To: City of Po way - Steven S. Salvati
From: Glen and Julie Seebruch ~h <, J ~
Dispute: Booster pump was submerged in water/silt and damaged due to new retaining
wall and silt guard fence placement at new water tower project on Skyridge Road.
/1-;;;;;,,- Z.,..:;-
The construction ofa new retaining wall as part of the 'High Valley water tower project'
and associated silt guard (fence) retained water to the level that it submerged our booster
pump.
Sequence of events leading up to December 31 st:
Retaining wall was built adjacent to booster pump area (south end)
Silt guard (fence) was built down hill and adjacent to booster pump area (north
end)
Drainage from east and west side of retaining wall, from retaining wall drainage
pipe, and runoff from top of retaining wall inundated silt guard causing flooding
to our booster pump during a rain storm.
Water and silt filled booster pump area and submerged our pump
Extreme condition then caused silt guard (fence) to break
Repairs were then made to silt guard and included new sand bags, digging out our
booster pump, and redirecting runoff.
By this time our pump had already burned out by water getting into motor case
and electrical connection box.
Due to this, we noticed lack of water pressure on New Years Eve. The following
day we tried to find a repair person but none were available due to the holidays.
We were unable to speak to any repair person until Monday morning.
We then decided to notity the City about this problem.
We were out of water pressure for 7 days which meant using a pail to fill our
toilets, trickling (long) showers, no use of washer, dish washer, sprinklers, etc.
This was a horrible week!
Note: Prior to new retaining wall and silt guard, flooding never occurred around
the water pump area during anv heavy rain storm.
8 of 16
April 26, 2005 Item #--1L
City of Poway
IQ IECElVE~
2 0 JAN mas
City Date Stam
CI'IY OF POWAY RISK MANAGEMENT
CLAIM AGAINST THE CITY OF POWA V
Received by
U.S. Mall
Inter-Office Mall
Over the Counter
!J~
via
X'
A claim must be filed with the City Clerk or Risk Manager of the City of Poway within 6 months 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
additional paper and Identify information by paragraph number. Completed claims must be mailed or delivered to The City of
Poway, 13325 Civic Center Drive, Poway, CA 92064 (P.O. Box 769). Alln: Risk Manager.
TO THE HONORABLE MAYOR AND CITY COUNCil, THE CITY OF POWAY. CALIFORNIA
The undersigned respectfully submits the following claim and information relative to damage to persons and/or personal
property:
1. Name of clai~ant JJo.~'c& Ca b \~ I
a. Address of claimant
b. Phone No.
c. Date of BirtL
d. Social Security No.
e. Driver's Lie. No.
2. Name, telephone and post office address to which claimant desires notices to be sent if other than above:
3. Occurrence or event from which the claim arises:
a. Date _111 ~"l .I olt
c. Place (exact and specific location) _11.1,":).4.1 5,11l-tJ
b. Time ~
{C,Jy.. (lJ.
\'..'0
) OM..
d. How and under what circumstances did damage or Injury occur? Specify the particular occurrence, event, act of omission
you claim caused the Injury or damage (use additional paper if necessary).
),t a-\-l-Qd\~>,-
e. What particular action by the City, or Its employees, caused the alleged damage or Injury?
SIlL G.""<'l("'MPl\;-
9 of 16
Attachment 3
April 26, 2005 Item #...lP.....
4. Give a.descriptlpn. 01 the injury, property damage or loss so far as is known at the time of the claim. If there were no Injuries,
state.'No Injuries." " , ,
(,0 i!t.... Ill- lvoDJ ~\M (..)Q5 d,\.j.rQ~J. rk ~u W<>J S L_~ kist.
to 5"a..J wxK .. Sftt- c,/\( ~ .
. '.. ..." I
5. Glila oal)'le(s) of the City employee(sj causing the damage or Injury:
,
N<>r<<.
6. Name and address of any other person injured:
~0i\L
7. Name and address of the owner of any damaged property:
Jtr.. /'to I Q \'0"'-
8. Damages claimed:
a. Amount claimed as of this date $ d,S"50, 00
b. Estimated amount of future costs: $
c. Total amount claimed: $ :}S.fO, cO
. d. Basis fBfOOfflJ*ltation of amounts elaimed (inelude copies of all BiIIs,inveieesieslimales, etc.)
~S-h_... C){t. '.,,<\.oJ,.1 rOP7)' Th'~ ,:ISh,....... H Q,r rH\a(\" -I\.. dr'w"'1d CMu. (J,I.\., ~S-. ~f<.
\"\QI-tJ',..!,l I J~k ) !.It',,l,,>- I e~c.
9. Names and addresses of ell witnesses, hospitals, doctors, etc.
a. ~J',J C<l\-'sc.l
b. \QM~ C~~l~l
c.
d.
10. Any additional information that might be helpful In considering the claim:
WARNING: IT IS A CRIMINAL OFFENSE TO FILE A FALSE CLAIM I (Penal Code !i72, Insurance Code !i556.1)
I have read the mailers and statements made in the above claim and I know the same to be true of my own knowledge, except
as to those mailers stated upon information or belief as to such mailers I believe the same to be true. I certify under penalty of
pe~ury that the foregoing is TRUE and CORRECT.
Signed this :10 day of ~
Claimant's Signature --<~
';}tJ<>$
,;.eo.
,at
Office of the City Clerk
Poway, California
DOCUMENT NO.
FILED
10 of 16
April 26, 2005 Item # 1 b
Attachment to Claim Form
Claimant: David Cabral
3(d) About 1:30 in the morning on December 29, 2004 a large Eucalyptus tree fell
from City of Po way (City) owned property into my backyard. The tree crashed down
onto my wood fence which runs on the property line which separates City property from
my bac:kyard, destroying 60 feet of fencing.
3(e) The City is responsible for the damage to my fence because it planted a n0n-
native species of tree, Eucalyptus. onto its pr"P"'l,. close to b: JIlopaly 1iDe ktw.....
City propaty aod my property, Eucalyptus trees are known for their sballow root system,
and a propeosity to uproot and fiill.. Further. the City fililed to properly maintain the tree
in such a -- topllM:Jllb:tree &om &Iliqg
11 of 16
April 26, 2005 Item # \ b
City of Poway
~ ~ "~ :: :~ ~
City Date Stamp
CLAIM AGAINST THE CITY OF POWAY
Received by
U.S. Mail
Inter-Office Mail
Over the Counter
5)~
CITY OF POWAY RISK MANAGEMENT
><-
N~ P;k.
(,O'f'O" .-0 1- ~
'f~ krJff-
via
A claim must be filed with the City Clerk or Risk Manager of the City of poway within 6 months 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
additional paper and identify information by paragraph number. Completed claims must be mailed or delivered to The City of
Poway, 13325 Civic Center Drive, Poway, CA 92064 (P.O. Box 789). Attn: Risk Manager.
TO THE HONORABLE MAYOR AND CITY COUNCIL, THE CITY OF POWAY, CALIFORNIA
The undersigned respectfully submits the following claim and information relative to damage to persons and/or personal
property:
1. Name of claimant
a. Address of claimant
Jose
,-fA. k" r-A
I
b. Phon~No.
/
. ._c._Date of Birth
d. Social Security No.
e. Driver's Lie. No.
2. Name, telephone and post office address to which claimant desires notices to be sent if other than above:
3. Occurrence or event from which the claim arises:
a. Date ~\ "Zc:a,::>
c. Place (exact and specific location) {/Ofr1 e~AOO R.(J
,
d. How and under what circumstances did damage or injury occur? Specify the particular occurrence, event, act of omission
you claim caused the injury or damage (use additional paper if necessary).
MA-'\J6l"I'IVA -p~ PDmGi2-"".DO C)!..U::>AAJDO foR.. 5a..lf~ i<i'hNCH AL (2.?,DeDofL
t5- UNA.5 5 ~ C.Al 5 uN t.\v '0 r::/(4CTU/b4N osG 0 .D/MJA-/V'(>>.s.;
7!::-J R-,rJ 1'/1\1'1 TA Y A\- G7v NOS 1", c;r'Ros j)€ U'I fE,=pe".J G!o'rJ
I
b. Time tb . -30 A -7""\
~ SCX"f'5 t2.4r--lGH
e. What particular action by the City, or its employees, caused the alleged damage or injury?
No VI2.EOc..u plH2..<5e
~I.J ~yo.
Po-t
(-A (~ilG Y DeJI'Ill
Qu6 5~ !if"S, 6Z4
12 of 16
April 26, 2005 Item # tb
Attachment 4
4, Give a description of the injury, prope damage or loss so far as is known at the t
state "No Injuries."
of the claim. If there were no injuries,
No IN)()y,es
5. Give name(s) of the City employee(s) causing the damage or injury:
6. Name and address of any other person injured:
No 1-NJUY' es.
7. Name and address of the owner of any damaged property:
Uo.sG' y'A!::.U rA ~':;>"Ht .<\tV'\
C\4u U. VIS+fl CA cHoUl
8. Damages claimed:
a. Amount claimed as of this date $ B' 3. J 3
b. Estimated amount of future costs: $ \..l N l:: NO u.J ^v
c. Total amount claimed: $
d. Basisfur compYtalion of a_tsclaime4{irn;luQecopi8S-Gtalt~ invoices, estimates,et&.)--------
9, Names and addresses of all witnesses, hospitals, doctors, etc.
a,
b,
c,
d,
10, Any additional information that might be helpful in considering the claim:
WARNING: IT IS A CRIMINAL OFFENSE TO FILE A FALSE CLAIM! (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 matters I believe the same to be true, 1 certify under penalty of
perjury that the foregoing is TRUE and CORRECT.
Signed this
1
day of
NA-Itc.~ ~ .
-----
." 2.ro5 ,at C,,,{ oF-
I
PA-IJ.J A L/
,
Claimant's Signature
Office of the City Clerk
Poway, California
DOCUME~~.16
FILED
April 26, 2005 Item #~
Claim from Jose Yakuta
Date of incident 2-23-2005
d. I was driving on Pomerado, crossing via Scripps Ranch about 5 yards I fell into a
hole. Fracturing/damaging the tire rim, the tire and some of the suspension.
e. Not taking care to maintain the road and allowing a hole to form.
Translated by Joann D. Flees
14 of 16
April 26, 2005 Item #---llL
City of Poway
IE ((: reD tile
CLAIM AGAINST THE CITY OF POWAY
-4 MAR m
City D<lte Stamp
8/TV'v . . '.' "'T
llt!'OWAY RISK MANAGEME"
Received by
U.S. Mail
Inter-Office Mail
Over the Counter
fJA&
via
'N~w r,'lC
(O'l-o<;,-o?-q
\\v..b;-I;,,'
~
A claim must be filed with the City Clerk or Risk Manager of the City of Poway within 6 months 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
additional paper and identify information by paragraph number. Completed claims must be mailed or delivered to The City of
Poway, 13325 Civic Center Drive, Poway, CA 92064 (P.O. Box 789). Attn: Risk Manager.
TO THE HONORABLE MAYOR AND CITY COUNCIL, THE CITY OF POWAY, CALIFORNIA
The undersigned respectfully submits the following claim and information relative to damage to persons and/or personal
property:
1. Name of claimant 12 0 Y H AS I g J
a. Address of cl~imant
b. Phone No. _
c. Date of Birtl
d. Social Security No.
e. Driver's Lie. No.
2. Name, telephone and post office address to which claimant desires notices to be sent if other than above:
RDV' J-Ip, RIB' ,
/
.1,"\\O~12..\...1 \~\7AC'I4.. ....A.qI9Jc
3. Occurrence or event from which the claim arises:
a. Date d'5~"?-"-1. ..&-2.4;. cr. n 9- 2 f_ D J b. Time
c. Place (exact and specific location) I 'Z. SIW r::..o/ &lIOn lit'" V. Pow-&> Y,CA.; 9ZD 6 4-
d. How and under what circumstances did damage or injury occur? Specify the particular occurrence, event, act of omission
you claim caused the injury or damage (use additional paper if necessary). r l\ 1'1\" Y ,,1? 2.....) -+'1... Po c t'c work S
f"."" ,.t"obL~.... " ",:-H>. ~.. ",.-te; r.. <(lrvoi.r ~.."'(-+J,t!' Pu!.L I;" ,.".oh.- s ~""ptD~,,<!'s L..4..e +0
i:l!t ('~J,#l'jt!' -#"10 Ivta-t-...y I"'-t.l> MY Py",p"Y"fY. Tt,; < 1""..,/ C6U(''''''/ 'fir -...r"'V e>y~ ";.,,., ~!n,b(P^"
w;~ M' P......nPlPv'Y: ;'J,rl,.l'L ""ot'Ut/' P{lhL;,.. 'NQrl,<!i..~ t""adp rru.""I~"~k~r=" o..fL,t::i/I#Y.
a-Y/~ ....i-ly J<i-o!:"""'lr;hl/rAD+-JvV w#-r4l",....... +"c"I'Y""+--+~"'v"o';'.... p....obu.-.....,
e. What particular action by the City, or its employees, caused the alleged damage or injury?
lriS"/~l~.,~-rCJ ,a';rc'+J>J':l'" vv""t-.... ;n-t'o P",oPI.,,'.s pv~p",,;+/~<_ rn""oh-rl1<"~d"J-.I/'l-;Y./
fr/'Yi/b;Y"..e i'D"<:' WI" J,,<;,.,,(,e; (0+"..,('.1'",;_. -r}.,c ,,,..-+-...,,. "...<,J/v",i,.,. bpl"~......., J !/f"II..,.,.
VlIJ.eYl ;+ Ye~/.J,,,,,(" Ci!!~/;' (.cv", /1>e ""D-t~ V~""'" Hot? tr,.,I/"L VAlue h~r~_...' n"'.......
/j"oI.pJt'/'.,C'~ t~n--6"J/ u.n, LJh;/"),JJv#;~ ~;'+/"l
T#/'(f' }..s""o) ~ ~nf;J,,;~~ 7'0 CO) Attachment 5
Lr,(..v\/II;......t>nPl' ~v'ry"/'l~n;1 PYD Pt9
~:p~:~;;~;2~i;;~~::;
,ex i' 1fil ~" IN'a-r,,,r R...'ft'"",,,,,,..;,,..
~;~~ ~~~1~~~ :~h;~\r:lj' ~op, damage or loss so far as is known at the. J of the claim. If there were no injuries,
I'~-' - '
,i ~ ~ : d "
\ " i ' 0 ...r-+-.
......._, ,
, ,
. Givb nm,m,ell1) ,~ ,me .g-a;;~J,nlCY e(s) causing the damage or injury:
'f"f)!'.~-';'i'.H"" .. ),"Hl\,l,\ ;~~ ;'TWT'"J
",.,. '.. '.. . ' n/ t' "",1-.:
6. Name and address of any other person injured:
MAwr.'>" HAl?l [31 ,(FAMILVJ.
7. Name and address of the owner of any damaged property:
8. Damages claimed: IB'D~ To 3-r- pet....r....;~<".e"
a. Amount claimed as of this date $"\ e (:)
b. Estimated amount of future costs: $ T 6' D
c. Total amount claimed: $ \' B 1)
d. Basis for computation of amounts claimed (include copies of all bills, invoices, estimates, etc.)
c.
d.
10. Any additional information that might be helpful in considering the claim:
WARNING: IT IS A CRIMINAL OFFENSE TO FILE A FALSE CLAIM! (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 matters I believe the same to be true. I certify under penalty of
perjury that the foregoing is TRUE and CORRECT.
Signed this ~ Jl.a.l..r~ day of ,t:) '?- ., - D !:
Claimant's Signature ~ f;fp~ ~"-
....w- .
, at
C I-rV o-f
Pn 'v.l a Y
.
Office of the City Clerk
Poway, California
DOCUME~TEflcSf 16
FILED
AII.;I 26, 2005 1l..111 #-I:k.