HomeMy WebLinkAboutClaim No. 552 - Trisha JefferyD
REQUEST:
DATE:
CONTENTS:
Recommendation:
CITY OF PALM DESERT
COMMUNITY SERVICES DIVISION
CITY CLERK OPERATIONS
STAFF REPORT
CLAIM AGAINST THE CITY (#552) BY TRISHA JEFFERY IN THE
AMOUNT OF $1,057.98
July 14, 2005
I. Staff Report
II. Claim No. 552
By Minute Motion, reject the Claim and direct the City Clerk to so notify the
Claimant.
Background:
Based on a review of the subject Claim and the recommendation of the Claims Adjuster,
Risk Manager, City Attorney, and staff, it is recommended that the Claim be rejected.
Discussion of this item should be held in Closed Session pursuant to Government Code Section
54956.9(b), potential litigation.
Submitted by:
RA HELLE D. KLASSE , CMC
CITY CLERK
Approved:
CARLOS L. OR A
CITY MANAGE
rd k
Attachment (as noted)
SHEILA R. GILLIGAN, CWq
ASST. CITY MANAGE F,fi6 R
COMMUNITY SERVIC /P.I.O.
H WPdata1WPD0CStCLA1MSl552 reject stafrpt wpd
CITY OF PALM DESERT
CLAIM AGAINST THE CITY OF PALM DESERT t ASSIGNED CLAIM N0.
CITY C!l�R�C'S OFFICE
(For Damage(s) to Person(s) or Personal Property) P p, L M DESERT • CA
2005 JUN 14 PM I: 45
Received by:
via: U.S. Mail Interoffice Mall Over -the -Counter
A CLAIM MUST BE FILED WITH THE CITY CLERK OF THE CITY OF PALM DESERT WITHIN SIX
MONTHS AFTER WHICH THE INCIDENT OR EVENT OCCURRED. BE SURE YOUR CLAIM IS
AGAINST THE CITY OF PALM DESERT, 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
CLERK, CITY OF PALM DESERT, 73-510 FRED WARING DRIVE, PALM DESERT, CA 92260.
TO THE HONORABLE MAYOR AND CITY COUNCIL, City of Palm Desert, California:
The undersigned respdctfully submit(s) the following claim and information relative to damage(s) to
person(s) and/or personal property:
1. CLAIMANT INFORMATION:
NAME ( ti
ADDRESS y
PHONE NO.'
SOCIAL SEC
2. Name, telephone number 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:
i
a. DATE: o b. TIME: c. PLACE (exact and specific
location
m 6
d. How and under what circumstances did damage or injury occur? Specify the particular
occurrence, event, act or omrnis ion you c im ca d the injur ` or damage. (Use
, Iditional pa er ,',f ecessary,} ` v r
-M
e. What particular action by the City, or its em oye s, caused th alleged damage or
Vf'l
injury? +O5 �_ p
_C-j'L� .�V aUL-AXY1.P
Page I of 2
4. Give a general description of the indebtedness, obligation, injury, damage, or loss incurred
so far as it may be known at the time jf� pre�sen ation of th claim. If ere wgre no
injuries, state "no injuries": '0 i/I M1,1 s IO'1TQ l -hY12
5.
6.
7.
Give the name(s) f the City employee(s) causing the damage or injury:
,ire, 4-
Name and address of any other person(s) injured: It ► 10 Y-l- <
Name an erif thp r o a dama ed roperty: JQ tfP,4, I
f
8. Damages claimed:
a. Amount claimed as of this date: $ / , 05-7 a�
b. Estimated amount of future costs: I
c. Total amount claimed: 11 "IV
d. Basis for computation of amounts claimed (include copies of all bills, invoices,
estimates, etc.):
9. Names and addresses of all witnesses, hospitals, doctors, etc.:
10. Any additional information, including police reports, which might be helpful in considering
this 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 da of _t�,�(,►�(�Q_ , 200 at
SIGNATURE O CL I INT SIGNATURE OF CLAIMANT
Office of the City Clerk, Palm Desert, California DOC. NO. DATE FILED
Page 2 of 2
AMERICA'S LARGEST Financing Available
INDEPENDENT TIRE COMPANY see store for details
DATE: 05— IB--2O05 5, •i IniE:. .':�; ISM
• •- •INFORMATION STORE• •
TR I SHA JEFFERY i 99 'iE ROLET
!� 51170 P IL-FlUP 81124 HWY i I l
21WD ALL INDIO CIA 92clet!.
IrsILEA6 : 109, 201 PHONE: 760-•7: 5—'-r36
PLATE #t @NEW 001 L A' RRV CH I SHOL.N
TORDUE SPECS: 100 LBS WORK ORDER#
._
CODE CC QTY SIZE �•� '" -"-_....;...._.,..,.,._. DESCRIPTION ." __.._ -._.
80085( NRM
33156 NRM
WARRANTY:
COMMENT:
80017 NRM
80075 NRM
80224 NRM
80219 NRM
80402 NRM
COMMENT:
4
I -ABOR
WHEEL. POLISH AND 9EPA I R
.00
100.00
400.00
4
: 25/4►Z+Zk-18 e8W R
KUMHO ECSI'A SUP60 712
. kj@
111.00
444.00
WORIJ,MANSHIP/MATERIALS•-LIFETIME ROAD
HAZARD -FREE
REPLACEMENT
I14PACT
BREAK ON TIRES AND
BENT WHEELS ON IMPACT.
4
CERTIFICATES
FOR FREE REPLACEMENT
.00
13.50
54.00
4
STATE REOUI RED
ENV I RON14ENTAL FEE
rr 00
1.75
7.00
4
WASTE TIRE DISPOSAL
FEE
• vio
2.00
8.00
4
INSTALLATION &
LIFETIME 5PI11 BALANCING
.00
1124.00
40.0101
4
VALVES, ROTATIONS &
LIFETIME REPAIRS INCLUDED
.4101
.00
.00
:��jj
n r'�,�$�'Asa
`•ivc's'Q`r.z
�.� �"•till.,
:Y:.., •;,:•i-.
� �, <:,:• .. ���...' .
. ... ).t :,.
yrt
'MKT. N' •s�.. •i''.,•!i .�1
;.
r.
WORK ORDER
LF RF
Air Check
Return Tires
❑ Change Snows
[ER] RR
Repair
Rotation
Rebalance
❑ Wheel Lock Key
Installed / Pretorque
Torqued by:
Ft. lbs.
Bay Coordinator:
Comments:
SUBTOTAL:
TAX:
X
Cust4mer(ySq at
Cardholder acknowledges receipt of good and/or sery es in the amount of the Total shown hereon
and agrees to perform the obligations set forth in the Cardholder's agreement with the issuer.
tiresillicom
953.00
35. 03
988.03
998.03
988.03
STATE OR LOCAL TAXES AND, WHERE REQUIRED OR CHARGED, ENVIRONMENTAL OR DISPOSAL FEES ARE EXTRA.
Repair Order #
180
Estimate Ref # 0
Date Printed: 06/14/2005
12:36:27PM
Repair Order
JEFFERY, TRISH
(' L $ L AUTOMOTIVE Page 1 of 1
81854 Industrial Place Suite # 8
Indio, CA 92201
Phone -4760) 863-4625
Hat/ref # Promised Time:
1999 CHEVROLET S10 PICKUP L4 2.21- Date Written: 06/14/2005
Written By: Larry
VIN:
License: AIM Mileage In: 0 Save Old Parts: No
Unit #: Mileage Out:110964
Name Description Uty List Extended
S10
Labor — Rate 1 FOUR WHEEL ALINMENT 69.95
SubTotal $69.96
By law you may choose another licensed smog check facility to perform any needed repairs or adjustments that the
smog check test indicates are nessary
Parts
Labor
Sublet
Misc
Hazmat
Supplies
Tax
Total
$0.00
$69.95
$0.00
$0.00
$0.00
$0.00
$0.00
$69.96
I hereby authorize the above repair work to be done along with the necessary material and hereby grant you and/or your employees permission to operate the
car or truck herein described on street, highways or elsewhere for the purpose of testing and/or inspection. An express mechanic's lien is hereby
acknowledged on above car or truck to secure the amount of repairs thereto.
Authorized By Date Time