Item 14B - Claim for Damages - Elinor KjeldsenGENDA REPORT
CITY OF POWAY
This report is i
( C32Y CIF F(IWAY
�a� JUN 24 1986
wAT TES crrY � pamy
- is
}F` . R E.
Received � � y C� C OF POWgY
via F D ERK'S OF
�ICL
tT S. mail Clerk' Time
Inter -office Mail UUN 2 41986
Over the
counter
_a
MIN SERV DEPS` _"o
A Claim must be filed With the. City Clerk of the Cit�r of
win .',,v^^u as
Wh3.C.1 the: 1nCtdedit Or event Occurred days after
BeB e your claim, is against the City of r`
ra7r notanother •
he entity. Where, space is w�sufficient, pease use additional;
PeP identify information keg►aracZA
Ah number. tpleted elate.* must aae: nailed
• or cieliv+ered to the City CJ.erk® qty of Y 15325 Cigic Center 13rve Poway,
G 92064 Q'00. Bow 785) '
y
TO TEE excRABrz
nym AND cmy cm7N=,, THE CITY `C p Paw CALMRNTA
The undersigned respectfully mgnits the following china and information relative to
damage to persons and/or personal property k
1. NAME OF CWLuvM Elinor Rjeldsen
a. ADDRESS OF CLAIMADM •
b. pBoDm No. c.. DAZE OF B3RM
d. SOCM 'X NO.
EPITMIISLXC. ice.
Z- 14airep, telephone and pont office address to which claimant desires roticcs to be
sane if other than above:-
3. 0=urrence or event frame which the c131tR arises:
a. DA'L'E= May 16s, 19 TIME aPpx .
6 PMC, PLACE (exact and specific iocat on)
Sidewalk on Poway Road, right in front of Home Federal Bank
near corner of Pomerac`
d. Eaw and under what a ==tances did damage or injury occur? SPwify the.
Particular` Occurrence, event, act, or cmission claim caused •
damage fuse a�ddit gnat the in.Jury Or
_. pap4er if necessary),
T 31•6.s wa 1. 1�.!...e r, !tea' Aides M1k Qn- A..- i al& gd i33 -M- 1 the d = of -
:1
f:
The metal door:: a ed
Federal is not. flush with sidewalk on, one end and have sid _ Rome
'
flush with walk. and I tr% ed n e bolts bolts. which are not
e. What
particular action by the City, or .its emg�®yeas, caused the alleged
dMge or. a.nlury?
Numerous metal bolts which are:not,flush with the sidewalk, and
metal encasement embedded in sidewalk.
f
2 of 3 AUG 19 3986 -ITEM; 1413
Give a descriptiop of the injury, propertydamagepr- loss, so far as is known at
the time of this Lim. a wi
were no njurie. state "n94njuries. "'
brokera bane in my ankle (fibula) and am now wearing a cast.
Give (s) of the City esployee(s) causing the damage or injury
Unknown
Name and address of any other person injured:
None
Z. Name and address of the owner of any damaged propertys
tv of Poway or Home Federal Savings & Loan and/or company who
put metal door in sidewalk, "owner" unknown.
Damagesclaimed:
a. Amount caiimed as of this date: $ unknown as vet
b.. timated amountof future casts: $ unknown as yet
c. Total amount claimed: $' unknown as of this date
d. Basis for computation of anrunts claimer (include copies of all bills,
invoices, estimates, etc.): N/A
Names and addresses of all witnesses, hospitals, doctors, etc.
• pnmorPelo ; r L,ital Emergency Room - Poway CA
Orthopedic Doctor for Smith
Did not get name of witness who helped me .up from sidewalk.
d. ,Askedto use phone in emergency at Pizza Hut.
10. Any additional, information that might be helpful in caonsidering this claim:
m
WARNING: ir IS A CRIKINAL SSE TO FILE A FALSES CUM! (Penal Code §72; Insurance
§556.1)
I have read the natters and statements made in the above claim and I know the same to
be true of my own knowledge, except as to those natters stated -upon information or
belief as to such natters I believe the same to be true. I certify under penalty of
perjury that the foregoing is. 'TRUE and .
Signed this , day of
Office of the City Clerk,
Poway, California
CCCUMENr NO. FILID
AUG 19 1986 ITEM 14$