HomeMy WebLinkAboutItem 3.5 Trinidad Montes Victoria Claim a
CITY OF DUBLIN
AGENDA STATEMENT
CITY COUNCIL MEETING DATE: June 25, 1984
SUBJECT Claim of Trinidad Montes Victoria
EXHIBITS ATTACHED Claim Form
RECOMMENDATION �. Deny Claim and Notify Claimant and City ' s Insurance
Carrier
FINANCIAL STATEMENT: Total Claim Undetermined - Claimant Estimates $725 . 31
in Damages
DESCRIPTION On June 13 , 1984 , the City received a claim form from
Trinidad Montes Victoria . The exact amount of the claim is unspecified,
however , Mr . Victoria lists $725 . 31 in damages . The claim is based on
alleged damages resulting from a traffic accident on May 7 , 1984 .
It is Staff ' s recommendation that the City Council deny the claim.
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COPIES TO: City Attorney
Ben Fernandez , Insurance Broker
•
ITEM NO. 31 Trinidad M. Victoria, Claimant
l` J
CLAIM AGAINST THE CITY OF DUBLIN
Control No. - -
(Office Use On y7
Namc of Claimant: T=10jDA'0 AINMES UIGTbe.(A R C C E I V E D
!,adress of Claimant: Il;_% (E�JfbZA� 'pJ � ti1(a &V S-66 'JUN 1 i W4
Sund Notices to: CITY Or" D ffiL'L_—_
uatu and Ifime of Occurrence: ��]� (� n
Mace of Occurrence.. (Provide detailed diagram describing exact location,
including physical landmarks or distinguishing land features, if appropriate.)
410 h 6, Az-km a } ,Daft rN
Circumstances of Occurrence: (If an accident, describe,physical conditions
, . surrounding occurrence, such as weatlier, 'road and -traffic conditions; etc.)
C `lncl Avn, CQ � c v4 Free �r-. ✓n r�1� 1�n �� ^rG- A :n Lbi
IR�t A',?- (I A,; t'h97M=dxa ai-41,. .50'Z�4 acid tc rfc ulll
17,-z T 4A-J.,ffd d6noLe 1000 .Le rl- Ifim u l en JLT h 4 44key V5P-'A6Vs Fes,"
ffyw rtq -rh,. -)rte% iy ilmc a su 25 f —h U I/l'�12� r� �
List names', addresses an phone -numbers of any witnesses:
,Mo s 3 7 Art oor- L& 9 1 u Dv6 ��T 6,
Description of Damage or Loss-. Pyc e i 0A 1"q q-e TAto 1'4
d r iA G.P< + r,,, D `1
. . 4
Name and Department of Involved City Employee (if any) : DA G\ ` ar- f
T�
Total Anount Claimed. (an-rtnc,L0, 1---A,9 Breakdown of Amount Claimed:
VV
Dated: //O Signed:_. __7
:,sore.: A claim relating to a cause of action for death or for injury to. rs or to pers`_-"il
property or growing crops shall be presented not later than the 100th day after the accrual
of the cause of aCUM. A claim relating to any other cause of action shall be presented not
later than one (1) year after the accii-I of the cause of action.
W= a claim that is inquired-to be present0d not-later than tha 3AOth clay after the
accrual of the cause of action is not presented within such time, a written application may
m_14e to the City council for leave to present such claim. 4he application shall be pre-
!-Lnt:od within a reasonable time not to exceed one (1) year after the accrual of the cause
of action and Stoll state the reason for the delay in presenting the claim. zhe proposed
Maim shall be attached to the application.
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e•!! p.A?T� A.:E NE`•'/ UNLESS OTHERWISE NOTED
Clam No. Dea'er No. ,
'.' 'o`'.sr-"-"f :'IZt•r!, i i:�✓:&au 5r .s I�alnul Creel: Honda 33115
35W N. Main Street —.--.
Walnut Crr k, California 94596. "t'N.�•rT.a Np. !
^E i.l-c� To pis (415) 949-1244
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i f,r'I H;,a+OA COOS�e•D.£�. T-ION Of PARTS AMOUNT —Via-,,tia��•--- w.�re NOS�6'! � L
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oiY AMO NT QT NOaCOS -O E ,
DE AI SCn Oa `TS .O S NT fo
ESRI I i E HONDA CODE O D cr O 0
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727.�G_la _ .—celiotG.
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THANK YOU cc 11
S�Z`o7 c0-0 1 et FOR THIS
OPPORTUNITY {{
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C&5 H ONLY CHECKS A ONL TO SERVE YOU. A
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Fyn a f3' ta' 4=i•) :ce l_' a, (CONTINUED ON BACK) so
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I nare,y authorize:na abo•a reoair work to Ce OOnO TOTAL LA BOA I a
along with in• ne Cessary materials.You and YOU ACtL �nar OSI 6
_ em oloyees may opera t.above veniCll I.,Purposes of
A, in,"CilO Or delivery al my risk,An exOress TOTAL pAnTS
nachamiC's I—is ackh.wll Cged on abOVe sahiCle t0 - ]
f—U,. the aM..nt OI re Da.rs thereto.Condl tons:
not re o—ibte for IOSS%damage to venl cle or artl- GAS.OI L.GREAKE
,as 1.11 In vehicles In Casa of tire,Ina rt,ac Cld.ht or LL
any OtMr cau fe beyond ow control.Storage will W SUWTOrAL(TaaaDU O
Charged commencing 46 hours after re oairs arts COm• hems) I f
SALES TAX `> 4
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