HomeMy WebLinkAboutItem 3.4 Robert Smiarowski Claim C I T Y O F D U B L I N
AGENDA STATEMENT '
MEETING DATE: January 24 , 1983
SUBJECT Claim of Robert A. Smiarowski
EXHIBITS ATTACHED Claim; Traffic Report; Underwriter Memorandum
RECOMMENDATION Deny Claim and Notify Claimant
FINANCIAL STATEMENT: Claim in the amount of $414 . 58 .
DESCRIPTION On October 26, 1982 , the City received a claim from
Robert A. Smiarowski for property damage to his
vehicle in the amount of $414 . 58 . Claimant alleges
that the damage was the result of hitting an obstacle
on a City street. This claim has already been
submitted to the City Insurance Carrier and has been
denied by the carrier.
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COPIES TO:
ITEM N0. 3.
RECEIVED
OCT 2 61982
CITY OF DUBLIN
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RECEIVED
�. - �- ---- OCT 2 61982 --- ----
CITY OF DUBLIN
DATE FIRST USE VEHICLE ID IFI A N MILEAGE YEAR Rt 1 MODE LICENSE N0. DATE3 2
UNITS 1.1E}4U I;AIIjT, SERVICE
/�i� L/ - 1 LUBE
12 V L[[Iff// (V 1 l SERVICE 1
eby authorize the repair work hereinafter set forth to be done OZZIE.DAVIS. 2350 First St. : Phone 447.8447 CUSTOMER.LABOR CHA /ARE DLR.CODE VISOR
I with the necessary material and agree that you are not respon• „ •�- •r: 2
for loss or damage to.vehicle or articles left in vehicle in case of MORE CAL.94550 ''BASED ON A RATE OF s _� �•;`, 'c'_ ;� ' OIL INGE
PONTIAC=TO LIVERMORE.•OTA .. ` CAL.B.A.R.REG.7r 1991: •�'� f, PER HR. s 2
theft or any other cause beyond your control or for any delays SF. PRO.DATE 3
ad by unavailability of parts or delays in parts shipments by the CHANGE OIL
tier or transporter. 1 hereby grant you and/or your employees „ r"^ ;'tj� .. j-;• ,.,� _ FILTER 3
fission to operate the vehicle herein described�on streets,high ''="' :G ,,, ': ].i`: TIME PROMISED Y' q REPACK FRT.
or elsewhere for the Purpose of testing and/or inspectbn,An '%/r'ne;•:,'C •1 �,/✓V "is - WHEEL
es mechanic's lien is hereby acknowledged AAAAAddddd above vehkle to .�. :.t ,:.r: OA.M. - BEARINGS 4 pM
r [he amou of repairs thereto. /! .yG?--'it,ic: ,.t_ - '^ -•,� S REPLACE
SERV. DVISOR P,C:v,
i` .�.• . VALVE. - 5
CUS OMER'S SIGNATURE ORIGINAL ESTIMATE, C' PHONE HEN READY - INSPECT 6
ADD'L.REPAIR BRAKES
'ODE(A-Q►RELATING ALL PARTS TO IW.C..)� 1PARTS&LABOR S ' BY . 0 N0�
BY 7 CHANGE TRANS.
AUTHORIZED X FLUID.
DTY. DESCRIPTION/PART NO. SALE ADD'L.REPAIRS 'S DATE TIME RES.PHONE ;r 7
I !•.. 'i^
I TOTAL S `" 8 CHECK
N r
E I ACKNOWLEDGE NOTICE AND ORAL APPROVAL OF AN . r Bus.PHONE SYSTEM 8
0 INCREASE IN THE ORIGINAL ESTIMATED PRICE. INITIAL. _ ___' _—__ _____ ' -- 9 ROTATE
I TIRLS 9
INSTRU IQ"N$ PAIR LABOR
E OPERATION.. UNITS MMO� _
147
A _ /- 10 BALANCE
WHEELS 10
B :•�.; :jtt<:' +tr /': r I i t'" ..i' ( .1 '- - i i r t 11 ENO N FRT,
I r_ 1 1
C 12 ADJUST
STEERING
D :err s:: :;i':;
SECTOR 12
QJ1A k_. j'y'' 13 SVC.EMISSION
E it` :.ri'ni Y°-Si i/( - CLEAIR
•� CLEANER 13
F ,,r-;; - .C!^ !i-. a`-,." _ ,r 1, .I •' 14 EECLS.
FILTER 14
G
/ ENG, TUNE
16 FLUSH RAD:
ADO
.:-s'.. :• :;: .;.v.f - COOLANT 16
J tr.i+} 17 ENG. FUEL
�- :ti .:�:,_�d ^j :�.. ;�:.{" ,ta" SYSTEM
FILTER 17
t8jCK. A/C
L ,1. a - v' ., vl &HEATING 18
I •N '.r� �:t•i
2-91 HEADLIGHT
M AIMING 19
). N0. SUBLET REPAIRS, N P +%y�r'':.tti�:':��"-' •i: ��' 20 WASH
20
0 ::.:,,`.._;..;.' l; .. 21 POLISH
P
may elect to charge for at ual much aics Iim al a rate of S ___par hour,but we will never exceed the maximum amount staled 21
In our wrl rin I
Q ,You will be charged no me a Than ti esllmal d price approved by you.Ilowavar,II we discovor that dillerent or additional repairs are indicated, 22 UNDERCOAT
•:you will be canl+cted for y tar adv+n: approv I 01 a revised estimate. 22
QTS. OIL @ 23
DESCRIPTION. :.:AMOUNT .
LBS.GREASE @ ..:;t a�`V�� �A 23
J LA80RMECHANICAL REPAIR LABOR SUMMARY
QTS.AUTO.TRANS, FLUID @
2-51 ENGINE
_ SUBLET REPAIRS COOLING 25
/E RECOMMEND THE FOLLOWING REPAIRS PONTIAC t PARTS&ACCESS.-MECH. _ ') 2-6J ELECT -
CHARGING
_ C _ (r SYSTEM 26
OZZIE DAVIS ZJ .17J LIGHT
�. RENTAL :: W0z REPANR 27
PONTIAC-TOYOTA
GAS,OIL,GREASE >W 28 HEAVY
2350 First Street ¢�4 REPAIR ze
•�.',:, ', ,.. ., 00a. 29 TRANS.
LIVERMORE, CAL. 94550 SHOP SUPPLIES 9E z� REPAIR 29
C Phone 443.8833 or 447.8447 Wa 3o DIFF a
UISt:L:.u.ICIt OF V7ANHANIIGS T1 TAX > ORI VI:
a Srllm, lu•rc IV rat,,r.:.al d1>,Lems J11 Z LINE 30
:*EXPLANATION OF SHOP SUPPLIES - A token charge Is Included for supplies
nm.ur> rnhm r..prr»r.l tar tan.. J. ,u T2 "used on your vehicle. Applicable supply itoms are: Nuts, bolts, .0,1s,s, laps. CHARGE 31 TRIM AND
.6..y v1,u,.pLo,l>.�nvury ul,,er,I,.,ue,blllty pins,aerospray,shellac,solvent.rugs,earheretor cleunur,towels,solder,battery GLASS 31
r.tl,e» 1.,, „ p.,.ul:rd:1, Iuul,u>.: ul,d ueul.er T3 cleaner,wire,window sealer,etc. CASH
„n,v> ,mr .,utr. rlre> enr nun:r nvlwa 10 OAUTOMOTIVE SERVICE CONSUL' It
a .,ta N
r 1i, day I., t.+11,I,vcuun wen 19.8546-2(ASC•104EA) ® At I.PAliI%RLMOVLU WRL UL SAVE DISCARD (4-78) ALL RIGHTS RESERVF' .
.• d.-..1 1..•rl.n 1` AVAII.AIItL FOR INSPLGf ON.
' _ FSTIlt4ATE COPY -"%
TRAFFIC COLLISION REPORT \ •AGE OF
SPECIAL CONDITIONS NO.INJURED H & R ITV JUDICIAL DISTRICT NUMBER
FELONY
NO.KILLED N St R COUNTY REPO,RTING DISTRICT SCAT
..So.❑ S o -k n
S
COLLISION OCCURRC 4ON 1 MO. DAY YR. TIME (2400) NCIC NUMBER OFFICER I.O.
Z _ c�._y!�t. ` 1t)( --------------------------------------------- ( 4o �Z �Z.Z-� �Zr
O MILEPOST INFORMATION
INJURY.FATAL OR TOW AWAY STATE
�-HIGHWAY RELATED
Q El VCS NO D YES SLNIJ
V FEET OF MILEPOST
Q PHOTOGRAPHS
J AT INTERSECTION WITH ,1�)
®OR: FEET/MILES Elyse- OF '�+j�(�Qr� YES O NO
PARTY ME (FIRST.MIDDLE.LAST) OWNER'S NAME SAME AS DRIVER
' .s�►" i c� s ? r X353 <kilo.
DRIVER STREET ADDRESS l` HOME PHONE OWNER'S ADDRESS Lj SAME.AS ORIVVKR `
PEDCS- CITY/STATE/ZIP (_'Il BUSINESS PHONE DISPOSITION OP VEH. ON ORDERS OF
TRIAN )4j W_ i 3 El OP PICER LL- DRIVER [:I OTHER
PARKED DRIVER'S LICENSE NUMBER STATE MO.SIR TH DATE SEX RACE DIRECTION OF Or/.CROSS (STREET OR HIGHWAY) !PEED LIMIT
VEH. 4 l
�I /�•/� D(A�//Y Y T AVEL
2A
I
■ICY- VEH.Y^/R(!) �LKE !)/1�M O.DeL ())//C�O.LOR( ) LICENSE NO. STATES) CH USE VEHICLE DAMAGE-E%TEN{/LOCATION
CLIST •� � 4> 1*+l. 'T-S'� (Iy ONLY W
j S
. �,�.� ;`�- VEH ICLH TYPE t/JS MINOR �MODERATE O MAJOR Cl TOTAL
OTMCR YYY°P°
1?4 2 AcL,
PARTY NAME (FIRST.MIOOLE•LAST) OWNER'S NAME I I SAME AS DRIVER
2 J
DRIVER STREET ADDRESS HOME PHONE OWNER'S ADDRESS Lj SAME AS DRIVER
PEDCS- CITY/STATE/ZIP BUSINESS PHONE DISPOSITION OP VEH. ON ORDERS OF
TRIAN D�I1
' OFFICER 0 DRIVER El OTHER
PARKED ORIVER'S LICENSE NUMBER STATE BIRTNOA TC SEX RACE DIRECTION OF pry/ACROSS (STREET OR HIGHWAY) SPEED LIMIT
VEH. MO. DAY YR. TRAVEL
■ICY- VEH.YR(S) MA KC(S)/MODEL IS)/COLOR(5) LICENSE NO.(S) STATE(S) CHP USE VEHICLE OAMAGC-EXTENT/LOCATION
.LIST ONLY 1 11
VEHICLE TYPE D MINOR �MODERATE CJ MAJOR O TOTAL
OTHER
PARTY NAME(PIRST.MIDDLE.LAST) - - OWNER'S NAME Lj SAME AS DRIVER -
3
DRIVER STREET ADDRESS HOME PHONE OWNER'S ADDRESS lAME AS ORIVER
PEDCS- CITY/STATE/ZIP BUSINESS PHONE DISPOSITION OP VEH ON ORDERS OF
TRIAN
OFFICER E DRIVER E OTHER
PARKED DRIVER'S LICENSE NUMBER STATE BIRTHDATC SHX RACE DIRECTION OF ON/ACROSS (STREET OR HIGHWAY) SICCO LIMIT
VEH. ,. - MO. DAY YR. TRAVEL
BICY- VEH.YR(S) MAKES)/MODEL(S)/COLOR(S) LICENSE NO.(S) STATC(S) CHP USE VEHICLE DAMAGE-EXTENT/LOCATION
CLIST - ONLY
VEH ICLE TYPE ❑ MINOR O MODERATE D MAJOR O TOTAL
. • . • . • . • . • . • . . • . • . . . • . • . . . . • . • • • . • . . . . . . • • • . ,
OTM C
PARTY NAME (FIRST.MIDOLE.LAST) OWNER'S NAME Lj SAME AS DRIVER
4
DRIVER STREET ADDRESS HOME PHONE OWNER'S ADDRESS SAME AS DRIVER
PEDCS- CITY/STATE/ZIP BUSINESS PHONE DISPOSITION OF VEH. ON ORDERS OF
TRIAN
OOPPICCR El DRIVER ❑OTHER
PARKED DRIVER'S LICENSE NUMBER STATE BIRTH DATE ISIX RACE DIRECTION OF ON/ACROSS (STREET OR HIGHWAY) SPCEO LIMIT
VEH. MO. DAY YR. TRAVEL
■ICY- VEH.YR($) MAKES)/MODEL(S)/COLOR(5) LICENSE NO.(S) STATC(S) CHP USE VEHICLE DAMAGE-E%TENT/LOCATION
CLIST ONLY -'11
VEHICLE TYPE O MINOR El MOOCRATE E MAJOR O TOTAL
OTN6R
CHP 555—Pace 1 (Rev 8-81) OPI 042
TRAFFIC COLLISION CODING
DATE Or, CC''OLLISION TIME (3.00) •• NCIC N(�Vw•MU1ER OP I�1,I��1/ 7d. NUMBER
MO. 1`l DAY 1kl YR. '-�4r/ � � �_.! • C/`�— i.��S �y1�('_/
PROPERTY DAMAGE
DEICRIPTION OF DAMAGE
OWNER'3 NAMC/A DORE SS NOTIFIED
T
O YES CJ 1 NO
VIOLATIONS) PARTY 1 PARTY 2 PARTY 3 PARTY 4
CHARGED
PRIMARY COLLISION FACTOR RIGHT OF WAY CONTROL 1 2 3 6 TYPE OF VEHICLE 1 2 3 4 MOVEMENT PRECEDING
(LIST NUMBER (*)OF PARTY AT FAULT) A CONTROLS FUNCTIONING A PASSENGER CAR/STA.WAGON COLLISION
A VC SECTION VIOLATION: B CONTROLS NOT FUNCTIONING B PASSENGER CAR W/TRAILER A STOPPED
' C,CONTROLS OBSCURED C MOTOR Cy CLC/3COOTER B PROCEEDING STRAIGHT
0 B OTHER IMPROPER DRIVING. D NO CONTROLS PRESENT - D PICKUP OR PANEL TRUCK C RAN OFF ROAD
E PICKUP/PANEL TRK W/TRLR D MAKING RIGHT TURN
C OTHER THAN DRIVER* TYPE OF COLLISION F TRUCK OR TRUCK TRACTOR E MAKING LEFT TURN
• D UNKNOWN• A HEAD-ON G TRK/TRK TRACTOR W/TRLR F MAKING U TURN
WEATHER (MARK I TO 2 ITEMS) B 31DE3WIPE H 9CHOOL BUS G BACKING
A CLEAR C REAR CND I OTHER BUS H SLOWING—STOPPING
B CLOUDY D BROADSIDE J EMERGENCY VEHICLE I PASSING OTHER VEHICLE
C RAINING E HIT OBJECT K HWY CONST.EQUIPMENT J CHANGING LANES
D SHOWING F OVERTURNED L BICYCLE K PARKING MANEUVER
E FOG G AUTO/PCDESTRIAN M OTHER VEHICLE ENTERING TRAFFIC FROM
F DYNER H OTHER: N PEDESTRIAN 3HOULDER,MEDIAN,
L
G WIND O MOVED ►AR KING STRIP OR
LIGHTING MOTOR VEHICLE INVOLVED WITH PRIVATE DRIVE
A DAYLIGHT A NON-COLLISION 1 2 3 4 OTHER ASSOCIATED FACTOR M OTHER UNSAFE TURNING
B DUSK—DAWN B PEDESTRIAN (MARK I TO 3 ITEMS) N XING INTO OF POSING LANE
C DARK—STREET LIGHTS C OTHER MOTOR VEHICLE A VC SECTION VIOLATION: O PARHED
O DARK—NO STREET LIGHTS D MOTOR VCH.ON OTHER ROADWAY P MERGING
STREET LIGHTS NOT E PARKED MOTOR VEHICLE B VC SECTION VIOLATION: Q TRAVELING WRONG WAY*
E DARK—
FUNCTIONING* F TRAIN R OTHER'.
G BICYCLE C VC SECTION VIOLATION:
ROADWAY SURFACE H ANIMAL: 1 2 3 4 SOBRIETY—DRUG—
A DRY D VC SECTION VIOLATION: PHYSICAL
B WET PIXSD OwJ� (MARK 1 TO S ITEMS)
C SNOWY—ICY h�\�J E VISION OBSCUREMENTS: A KAD NOT BEEN DRINKING
D SLIPPERY (MUDDY,OILY,ETC.) J OTHER O.J C : -. B HBO—UNDER INFLUENCE
F INATTENTION C HBO—NOT UNDER INFLU.•
ROADWAY CONDITIONS 7 G STOP$GO TRAPFIC DHBO—IMPAIRMENT UNKN•
(MARK I TO 3 ITEMS) PEDESTRIANS ACTION H ENTERING/LEAVING RAMP E UNDER DRUG INFLUENCE'
A HOLES,DEEP RUTS* A NO PEDESTRIAN INVOLVED I PREVIOUS COLLISION F IMPAIR MENT—PHY SICAL�
B LOOSE MATERIAL ON ROADWAY• CROSSING IN CROSSWALK J UNFAMILIAR WITH ROAD G IMPAIRMENT NOT KNOWN
B
C OBSTRUCTION ON ROADWAYS AT INTERSECTION K DEFECTIVE VCH,EQUIP,: H HOT APPLICABLE
D CONSTRUCTION-RQPAIR ZONE C CROSSING IN CROSSWALK—NOT I SLEEPY/PATIGUED
E REDUCED ROADWAY WIDTH AT INTERSECTION L UNINVOLVED VEHICLE - -
F PLODDED• D CROSSING—NOT IN CROSSWALK M OTHER': 1 2 3 4 SPECIAL INFORMATION
G OTHER.: E IN ROAD—IN CLOD ES SHOULDER N HONE APPARENT A HAZARDOUS MATERIALS*
H NO UNUSUAL CONDITIONS F NOT IN ROAD O RUNAWAY VEHICLE B FIRE INVOLVED*
G APPROACHING/LEAVING SCHOOL BUS C TIRE DEFECT/FAILURC•
JSKETCH - MISCELLANEOUS . -
UI - INDICATE
l
Z PHYSICAL DESCRIPTION OF PARTY
Q NUMBER HAIR CY[S NIIGMT WQIGNT
�-1
FR QIAR6R3 N M I.D.NUMBER MO. DAY YR, RCVICWCR'S NAM MO. OAY Y
CHP 555—Page 2 (Rev 8.81) OPI 042 *Explain in narrative
j
CH ONE CNECh JNE _J
NARRATIVE/SUPPLEMENTAL DNARRATIVE SUPPLEMENTAL COLLISION REPORT E) OTHER:
DATE O.ORIGINAL INCIDENT TIME (2♦00) NCIC NUMBER t O`r IICKR I.D. NUMBER
MO. DAY YR. Q\�`-J )^ 5 •`�
CITY/COUNTY/IUOICIAL DISTRICT RE►ORTING DISTRICT/BEAT �f�YYY VV
1 CITATION NUMBER
LOCATION/SUBJECT
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