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CC - Item 4A - Reject Claim - John L. Kyburz staff eport I TO: HONORABLE MAYOR AND MEMBERS ROSEMEAD CITY COUNCIL FROM: NANCY VALDERRAMA, CITY CLERK DATE: SEPTEMBER 22, 1999 RE: AUTHORIZATION TO REJECT CLAIM AGAINST CITY FROM JOHN L. KYBURZ The attached claim was received in my office on September 2, 1999. A copy was sent to the City's claims adjuster, Carl Warren& Company on September 7, 1999. Carl Warren & Company sent a notice on September 9, 1999, recommending that this claim be rejected by the City: RECOMMENDATION It is recommended that the City Council approve the rejection of this claim and authorize a letter of rejection be sent to the claimant. Attach. COUNCIL AGENDA SEP 2 01999 ITEM No. ce • MAYOR MAYOR PRO TEM: a MARGARET CLARK tail 0% ,�T 8838 E VALLEY BOULEVARD O.BOX 399 ROBERT W BRUESOH T ROSEMEAD, CALIFORNIA 91776 JAY G IMPERIAL TELEPHONE(626)288-6671 GARY A.TAYLOR FAX(626)307-9218 September 7, 1999 • Dwight J. Kunz Senior Account Manuel- 750 ana¢er750 The City Drive,Suite 400 Orange, CA 92668 RE: JOHN L.KYBURZ Dear Mr. Kunz: The attached Claim and Trac Collision Report was received in my office on September 2, 1999. The City does not have any prior information on this claim. Please advise as to the steps you-wish to take in this matter. Sincerely, NANCY VALDERRAMA City Clerk Attachment cc: City Attorney cla'Ims:adilvl • FILE WITH: CLAIM FOR DAMAGES RESERVE FOR FILING STAMP CITY CLERICS OFFICE C1. E6%;;-U P TO PERSON OR PROPERTY CLAIM NO. 99 INSTRUCTIONS CITY OF RO 1.Claims for death,injury to parson or to personal property must be filed not later than six IN Eris Le months atter the occurrence.(Gov.Code Sec 911.2.) J ��pO 2.Claims for damages to real property must be 0 �led not later than t year after the occurrence_ 99 (Gov.Code Sec 911.2.) 3.Read entire claim form before filing. CITY CLERK'S OFFICE 4.See page 2 for diagram upon which m locate place of accident 5.This claim tome must be signed on page 2 at bottom. it Attach separate sheets,ii necessary,to give lull details.SIGN EACH SHEET. Dale of Biof laimant To CITY OF ROSE?LEAD, 8838 E. Valley Blvd. , Rosemead 91770 /2/11/52 Name of Claimant Occupy to}n,of Claimant/I � �ctin L. ,ey.bur7 Cdi✓eltbonJ/eWOrtto( Home Address of Glaim t Cl1rr and Ste Home Telephone Number .541 { ever y Sr /eernp/e C,tr Cs- 9i7SO 626 287- 7800 Business Address of Claim Citynd Stale Business Telephone Number Freer?el'? ...Beard/Eq. ( • 4fia ee e . Give address and telephone number to which you desire notices or comMunications to be sent Claimant's Social Security Na regarding this cleim:3v(1A ciyouer/y �' 'Caigle C1. Ca. 549 '8 -/422_ When did AM E or INJURY occur?, / Names of any city eployees involved in INJURY or DAMAGE Date 523 q Time r4 CrO r)r'• Alt II claim is for Equitable Indemnity,give date claimant served t e. with the complaint: Dateive street Where did DAMAGE or INJURY occur?Describe Tully,and locate on diagram on reverse side of this sheet.Where appropriate,g names and address and measurements from landmarks: M/rtple City Blvd Valley I3!vid Describe in detail how the DAMAGE or INJURY occurred. riders -5/de of Vehicle_ J12niaJed /eight Pear Panel Why do you claim the city is responsible? —77—a C, Lights 4a1{unCcroi2 Describe in detail each INJURY or DAMAGE cture5 kuit (1 .Ge sthnzrtted SEE PAGE 2(OVER) THIS CLAIM MUST BE SIGNED ON REVERSE SIDE The amount claimed, as of the date of presentation of this claim,is computed as follows: Damages incurred to date(exact): Estimated prospective damages as far as known: Damage to property S Future expenses for medical and hospital care . . _S Expenses for medical and hospital care S Future loss of earnings S Loss of earnings S Other prospective special damages S Special damages for S Prospective general damages S _ Total estimate prospective damages $ General damages S Total damages incurred to date $ GO Total amount claimed as of date of presentation of this claim: S 2C O O /+ + • Was damage and%or injury investigated by Dice? 7c'S If so,what city? /e✓)7 t City Sit/{fee ,J)e, artiv7 rt* Were paramedics or ambulance called? e5 If so,name city or ambulance If injured,state date,time,name and address of doctor of your first visit WITNESSES to DAMAGE or INJURY:List all persons and addresses of persons known to have information: Name Address Phone Name Address Phone Name Address Phone DOCTORS d HOSPITALS 1 .[ ..}A Hospital rc2((/B /VIE f�'Kt�lst Address Date Hospitalized Doctor Address Date of Treatment Doctor Address Date of Treatment READ CAREFULLY For all accident claims place on following diagram names of streets, or your vehicle when you first saw City vehicle;location of City vehicle including North, East,South, and West;indicate place of accident by at time of accident by"A-1"and location of yourself or your vehicle at "X" and by showing house numbers or distances to street corners the time of the accident by"21-1"and the point of impact by"X:' If City Vehicle was involved,designate by letter"A" location of City NOTE: If diagrams below do not fit the situation,attach hereto a proper Vehicle when you first saw it, and by "B" location of yourself diagram signed by claimant. J� \ T (/o/Cey Si �� ,�� SIDEWALK ` CURB_--} — _ \\ �o y, CURB �� PARKWAY 1 1 9 . SIDEWALK Signature of Claimant or person filing on Typed Name: Date: his behalf giving relationship to Claimant: �G/ h / �/`/ 1 /.,,� C�/2/O9 ti L 1[ NOTE: CLAIMS MUST BE FILED WITH CITY CLERK(Gov.Code Sec. 915a). Presentation of a false claim is a felony Pen. Code Sec. 72.) STATE OF CRt6ORNA4. TRAFFIC COLLISION REPORT �/If�/l r l,/ /g:;(-)0 16'2 %QZQ ( L CHP 555 PAGE (Rev 2-92) OR 042 _ C ..o o. 7 s..u.L corms-ions lir '.^.O ,2 oscvr,�,q) RV '4 <,',=.a=-7 1/7 .,..Yfl LOS P;,6.„7.-Lt-es Sri:3 1� s? -, ...ph, a.c`5l - t-I'7( w. .n V 4-1-LCY J LRt' 4- i) DS i 23';51 i'-N✓✓ Pa \S ye '�D7F3 .Is.o...,A.. o - a .D..t.K ,.. . .D .Ln t$TWTFS [,�n ❑C **T.Rt..CCIlat CT"( � �J eem Lc C CT"( ii+2Q Wein/L. ❑a• ,.LA O. ❑.n1R1.4° 53%0.11 PARTY onvun ucessa mann ran .ism vitt TAAR .ut I SOoEL,caws _ a EK .SR STATE 1 4-757 (8%0 D GR G b } r7• a ,?1 ., F�c?c. . 5 ozzv&- c,4 morn Nun/PIRST.1•0041.LAST) 1$ R O 0.9147:0 r 4"t' 4 ., O '-fctZ fr./AtPUT- Gt¢aVc A-V. 6,R4SSD , Jtt❑cPa-OD ` , �pav .n=Ajc�Pax11777 1 977 &At t-c` be RDEsVf4Q 9r 3`ra 'Lyn Evil 4 ❑ A . , ❑aA CLOT r'\ urin^i z2 0116; ODAZ !µ t vcA-w�Y p (&z(-)2_52-36`1 ( ).�0.i .a ..t.�,,.L. :o....E ...OLIOAM EA li If'i�r-+t-r� ©IZ'3C3`iZ Gb'' auE a. O.'o. D.a...� DOTS C. 0 ,¢O .LC O r VAAWoeY 3L t-fD 21 4 Cie) vL PARTY o.rcw.LICENSE.W.cm v c ucn rca.un YAKS i'MODEL?=LO. uccxsc wuu.n nm 2 Aa 4' 4e,ID Grt G `U. 6.2 c�IZVYcpevrt,2, --.\•3-%.-10..%3 . 44 DRIVENSAME m..T..DDL .LAST) a D* L?Pv`f tC`eoR `te=xww o . ❑..YEASDv.. mo" Gip VevaLY el-ye. LRt,4*-DA , mtcr4ReL sk. :Eo ,Esta crrY. &4 . 1172-0 ✓k`;3�7 a. kikLmONTc AL', q,v&D OF OM ORDERS Of 2 �n-wn Y ❑a.w«. ®.,.c. ❑a C o \ io yr45LJ J 6FJ7 (Lc tz iY t , ni c2 W Jaty ap (026)�7-�BOa (—) ,a ,a...Ono,..a..m. o.,... r ...o..OW.cGED MO P-1°.-DC.-.. 43.“-P . ❑,OT wT0 CA0 ia0 .LCo AL1 � 1 iJ`f'ePA?L-c z-(7 «-• "1-0F PARTY Dwrers LICENSE nu..µ =. .cn.un .u,c,YODEL,COLO. aT.Tc a 3 W;1--)c4(28-4772- C I t6, ?5--7.171-C9-04, .1-ttptzr AAAA Li-abo3 et DmvE �^ `1,--r-CV c N th'11ZOFLIyn( 4.444 s5-{c me 4QEc/J 3QO. N . V4-Lu&T' V,-C..D S, �. . a..T. o .E❑`. o'ZA A—. c14. 928-to5 (63(.'.11 ❑>.Y...a..., ❑D.R..A DD.,. ❑aTwA ❑ P <ury1 31-IL1132', cc. 's(7 Cl 'µ DAT23F: 62 0 DYt1v,--r--r A-W/FY .a. wCAL FD .� . ..o.Io...CE.❑ O(1k ) "t2-36a7 (S ).7>`-&-8-£os . � . . . . .. ow .D ...L ..t , D.c.. 0.... mr-zr -cval PP_3702;+'7Co ..El.DC ❑.. . at 3 IvA4tt'( BL. YD KF DOT CA ICC0 Inc 0Tµ1a csPATcw NOT;,ED DEVIEWE'S NAME .n✓ 12C:r$r] 477 0YES 0 NO.LNIA DEP.D.MALER.62'22 DA5-F 2 c{-SJ F STA-"E OE CALIEOREUE TRAFFIC COLLISION CODING PACE l .A-EO : lrclbm, 0 ,1,S--- C-. Y .—OO .-ice. "-�o }� •-r24 -ac'-I-'17 1 PROPERTY OWNER tMWf ADDRESS nicl1RE LJEXON° DAMAGE DEScamw.OE DUEADi SEATING POSITION SAFETY EQUIPMENT EJECTED FROM VEHICLE _QM/PAM5 L.AIR BAG DEPLOYED 111/E&GT[I F.11F1 MP[ O.NOT EJECTED ® 1 A.NONE IN VEHOLE U- IR ABAG NOT DEPLOYED DRIVER 1-FULLY EJECTED B.UNKNOWNN-OTHER lr-NO 2-PARTIALLY EJECTED �' 1 C-LAP BELT USED P•NOT REQUIRED w yEs ]-UNKNOWN 1.DRrvFR D.LAP BELT NOT USED z 3 1TO6-PASSENGERS E.SHOULDER HARNESS USED PASSENGER 7-STAPON WAGON REAR F-SHOULDER HARNESS NOT USED SNLO RESTRAINT i Np 4 5 6G-LAP'SHOULDER HARNESS USED 0-IN VEHICLE USED Y.YES Y-POSIPON UNKNOWN 9- OS' OCC NKVAN H-SIP/SHOULDER HARNESS NOT USED R-IN VEHICLE NOT USED J•PASSIVE RESTRAINT USED S-IN VEHICLE USE UNKNOWN L 7 O.OTNER K-PASSIVE RESTRAINT NOT USED T•IN VEHICLE IMPROPER USE 2 U-NONE IN VEHICLE ITEMS MARKED BELOW FOLLOWED BY AN ASTERISK 1'1 SHOULD BE EXPLAINED IN THE NARRATIVE PRIMARY COLLISION FACTORMOVEMENT PRECEDING UST NUMBER (.) OF PARTY AT FAULT TRAFFIC CONTROL DEVICES 1 2 3 TYPE OF VEHCLE 112 3 COLLISION • AVC SECTION VIOLATED: A CONTROLS FUNCnOMNG p<•J( APASSENGER CAR I STATIN WAGON XASTOPPED 2) -11 21,4'53€4) C. C t yJB CONTROLS NOT FUNCTIONING' BPASSENGER CARNI/TRAILER X BPROCEEDING STRAIGHT B OTHER IMPROVER ORInrvL': 1V`CONTROLS OBSCURED C MOTORCYCLE(SCOOTER CRAM OFF ROAD DMO CONTROLS PRESENT/FACT011' XDNCKVP OR PANEL TRUCK XD MAKING RIGHT TURN IC OTHER THAN DRIVER' TYPE CW COLUSIOI E MCKUP I PANEL TRUCK W/TRAILER E MAKING LEFT TURN D UNKNOWN' AHEAD-ON F TRUCK OR TRUCK TRACTOR F MAKING U TURN A E FELL ASLEEP' B SIDESWIPE G TRUCK!TRUCK TRACTOR W;TRLR. GBAOWNG I REAR END H SCHOOL BUS H SLOWING I STOPPING ' WEATHER I MARK I TO 2 ITEMS D BROADSIDE I OTHER BUS I PASSING OTHER VEHICLE A CLEAR E HT OBJECT J EMERGENCY VEHCIE J CHANGING LANES A B CLOUDY IF OVERTURNED K NORWAY CONST.EQUIPMENT KPARK/NGMANEUVER IC RAINING ICi VEHICLE/PEDESTRIAN IL BICYCLE L ENTERING TRAFFIC ID SNOW NG IH OTHER': MOTNER VEHICLE MOTHER UNSAFE TURNING IE FOG:VISIBILITY FT. MOTOR VEHICLE INVOLVED WITH N PEDESTRIAN N XING INTO OPPOSING LANE F OTHER': ANON.COLLIAON °MOPED °PARKED 13 WIND PEDESTRIAN P MERGING LIGHTING ,( OTHER MOTOR VENOLE b TRAVELING WRONG WAY XIA DAYUGHT D MOTOR VEHICLE ON OTHER ROADWAY 1 2 3 OTHER ASSOCIATED FACTOR(s) IA OTHER': B DUSK.DAWN E PARKED MOTOR VEHICLE IMARK I TO2ITEMS) _IC DARK-STREETLIGHTS F TRAIN Arc SFrnouvaunw: CITED ____iiipl 0t - - _D DARK-NO STREET UGHis BICYCLE ❑" , E DARK.STREET LIGHTS NOTH ANIMAL: BvcPLrnwvaunw: 0 FUNLT1Oa XG' QYu SOBRIETY-DRUG ROADWAY SURFACE FIXED OBIECi: °p PHYSICAL NIA WETDRY —1 Crc.Frno.vaunON Ovo 1 2 3 (MARK1 TO2ITEMS) IB WET J OTHER OBJECT: Oso H()CXAaAD NOT BEEN DRINKING �C sxowr.lc BHBO-UNDER INFLUENCE ID SUPPERY(MUDDY,OILY.ETC.) E VISION OBSCUREMENT: F INATTENTION•: CHBO-NOT UNDER INFLUENCE' ROADWAY CONO1ONSI ' GSTO•A GO TRAFFIC D HBO.IMPAIRMENT UNKNOWN' (MARK ITO2ITEMS 1 PEDESTRIANSINVOLVED E UNDER DRUG INFLUENCE' A NO PEDESTRIAN INVOLVED ` HENTEWHGI LEAVING RAMP F IMPAIRMENT-PHYSICAL' IA HOLES,DEEP RUT' �B UNFAMILIAR INCRCSSWALK IPHEVIOUSCOLLSION GIMPMRMEM NOT KNOWNUNFAMILIAR WITH ROAD IB LOOSE MATERIAL ON ROADWAY• AT INTERSECTION H NOT APPLICABLE KDEFECTIVE VHS EQUIP: �-] IC OBSTRUCTION ON ROADWAY CROSSINGCROSSWALK-NOT D. SLEEPY IFATIGUEDD CONSTRUCTION-REPAIR ZONE AT INTERSES CTION °w SPECIAL INFORMATION E REDUCED ROADWAY M DTVI DCROBSING-NOTIMCROSSWALK LUMINVOLVED VEHICLE ANASARDOVS MATERIAL F FLOODED' IE IN ROAD.INCLUDES SHOULDER MOTHER•:dY T2 & L44,14-T- N G OTHER': IF NOT IN ROAD N HOME APPARENT NO UNUSUAL CONDITIONSIAPP110ACHINCILEAVING SCHOOL BUS ()RUNAWAY VExcLE SKETCH cITS2Lc CrY — 'aI INSCELxi0u6 �I 14 ADNJI PL rnY+a i. V,45 vW � 'C 'a .- � L. "� -It". -"=• 1=1 Yco h% :.' rte., _ � 1 7I o I I ?z 1 I CRP 555 PAGE2( RAV Ida)OPla2 iE Of GLIFORNIP INJURED I WITNESS I PASSENGERS CHP SSS Page 3(Rev.2-9)) OPI 942 PND.ll Of I 4 ) -fir1,40c7 <-42.. 9� -73 9s CR CauSION Ma _ f I 1 ' }FaR)SPi1 `f _. � 9 �49 v -on -`f7 I ,,,,:vs : nEN DE I 111 EXTENT OF INJURY CrONE) 1 INJURED WAS nr ONE) �P,ARrySEATtun, E_ urY :cur N)NRY PUN o. ) w ce _ 2JF1 I vP.3I* 1PN weA`11klVJ• (SI) - IS- Io15 r'n 0-5P-3PINJLL DREDDNTn,1..N=PygTEDPE mv,��w�cc TAKEN TDP* a\014\ MCS!-)t i I U`,�QITAU I u� Ni COWE111Altil Df QAlt-s ---'0 C±C41 ((2F f`N�_I_. rE Pcnm Ds noLzra pawDRo i V'a M 1 J I J I J ID E I r Li I iI 5 14 Q I C)H TELEPHONE (t{t1 � FVCVO N41K \AMA I7 - lz_a✓ rtn,= r+5 p-3 )(WIRED Y5 TRPSP NaFren y TnEN TD. DFswLENLJLwles LN.1uT2_t___ _ iJa CF L �G',DDD, > 1 I .: I I I I l I- I L I u i uE IMMUREDONLY)TRANSPwreD N. DEsoueE lNIUNIES J L 11 J 1 ❑ I ❑ ❑ M�.w%wE w NERVED �I TaENION ,NIJURED amn mwcwnTFD BY'. TAKEN TO .-. IDERCRIBE WORRIES —1I v,LTR Cir RE SOTIFlED Pi 1 r — ri 1 I I. - i [' SHAM i D 0 S iA MESS TELEPHWE n VICTIM 'ACCENT CR EN NDTIRED I I— -E __J — I RS yERBEN/N„ AINIURER ONLY)TRwSPORTEW BY SARRE.TO __. 0eSC I9E'NJUFEs MUM Of MCCENT MBE NOT F ED PREPARERS / EWERS MAME _ D.Y. YEAR r ed I EZ --.A �`'/�364 a5R 'cq -�___ OSP 9e 10338 STATE OF CALIFORNIA FACTUAL DIAGRAM CHP 555 Page 44Rev.8-97) OPI 042 PRw of Darr --_._s CO( OFFICER ID i fR -. aUUCP.(MO. YEAR) TIME v.om Tc.— ... R ALL MEASUREMENTS ARE APPROXIMATE AND NOT TO SCALE UNLESS STATED (SCALE* INDICATE NORTN I i I F 'XEPARED BY ID NUMBER MO w. YEAR ENFRSN de WO DAY YEAR • STATE OF CALIFORNIA NARRATIVE/SUPPLEMENTAL CHP 556(Rev 7-90)OPI Dat _ Page T_ _ DATE OF NCIDENLCCCURRENCE I TIME(NN/ NCCNUMBER I OFFICER ID.NUMBER NUMBER LOS 2Ti- -/QQ/ iv-tvo4 -a. 1.00.70 I9073 /i`1 _ c14-orl'74-oS% I- 147/ /po�� .x-D,E 1VPE SUPPLEMENTAL rr APncAaz E, igNarrabve L31 Collision report I BR update �I Fat ❑Hn and run update ❑Supplemental ❑Other: - _ ❑Harardous maRnals ❑School bus Omer: - OIY.mMINI1I.CHCME0L5TRCT II NEFORTMI/G M5IRCT�9EAT CRATONNUMBER (LrJsc M�diO / Los Angeles /rzto r�acsp 'aa.31 lS3T( /'Pn L9'2O`fe 'LOCATOF4! JECT 'STATE HIGHWAY RELATED VAL.L,=L( 3L , /re- riFt- GIT'! 4L. Lives No / 1 1. 1 . FACTS: a A. Scene: 3. 1 . Roadway # 1 : Name: Vett- Ler 3i. . a. ($4 Asphalt Surfaced ( ) Cement Surfaced ( ) Other: 5. YQ Business/Commercial ( ) Residential ( ) State Hwy (SIR # ) . ! 6. ( ) Private Property ( ) Parking Lot ( ) Other: 17_ (a Straight ( ) Curved (}Q Level ( ) Incline (e) Left Turn Bays B. ( ) North/South L ) East/West Divided Byrrub CA+ l..a.SLIO ‘fcwat,L ""- Srp : 9. Lanes in each Direction:lAdditional Description : • 10- 111 : 13- - _- —_ • 114. 2. Roadway # 2: Names-rap PLC Girls aL- , . 115. (ni Asphalt Surfaced ( ) Cement Surfaced ( ) other :__ • ! is. (JL( Business/Commercial ( ) Residential ( ) State Hwy (5/R # ) 1 117_ ( ) Private Property ( ) Parking Lot ( ) Other : 18. ($0 Straight ( )_ Curved c...)./ Level ( ) Incline (MM Left Turn Bays 19. ) North/South ( ) East/West Divided By :TwP Dool3Lii 496i0 Yortroo 1.-Pae 20, Lanes in each Direction_ L Additional Description: 21. • '22 21 24. 25. 3. Traffic Controls : ( ) None ( p. Tr -Phased (let Left Turn Arrows 26. _. _ ( ) Stop Signs ( ) Other Control( s ) : 27. Controls Located at : (�O Four-Way : or (_) Other ; 28. 29. 30. 31. EPARERS HANE AND IO.NUMBER DAT — - E REVEWERS NAME DATE ' c _ t_L1Z`.7eIJ 4*,73yel. rr-Z3-gg __ • TEM Use previous editions until depleted. x s.y, STATE Or CAUrCRNA NARRATIVE/SUPPLEMENTAL CHP 556(Rev 7-90)OR 042 Page 5---- [DATEipA}E Dr WCIDEMgLLURRENCF 1 114E(NLtlI WC NUMBER 1 OFFICER I.O.NUMBER, NUMBER p ' s-23 -`39 I`t rf2. 119 OO L/ 73F $ I!I 99-v>475-D5-3i- 41-,i 'CONE .r ONE TYPESUPPtEMENTAL rrAWUG9LEJ ❑Narravve ❑eornsion report ❑BA update ❑Fatal LI Hit and run update ❑Supplemental ❑Other. ❑Hazardous matenals. /1 Scholl bus ❑Other: i CFMCOUNTYOUOCal DISTRICT I REPORTING DISTRCTiBEAT CITATION NUMBER / Los Angeles / L- - !STATE NIG4WAY RELATED I ILCAT/ON91BJECi ❑Yes L.No I I1. B. Measurements: Obtained By ( ) Pace >( Rol-p-Tape ( ) Other: _. 2. (Al 1_measurements are approximate & rounded to the nearest foots ' 3 - 4 1 . AOI k 1 : 3I p� Ft W of the C E.,- Curbline of Qt, �173L,1 3 , 5. 4(oa Ft S of the N Curbline of VA-LA- ld 31.. 6. 9 7. AOI # 2: CO Ft "3__o_f_.he_t- Curb1 i n nF1 EM PLc 6 int SL. _Fj 8. -3�� Ft_.3 of_ the S Curbline of y L£Y 3L. ' 10_ AOI S 3: Ft of the_-__-Curbline of_. H - - __ Ft of the Curbline of 112. 313 _ .. ___..- - _ - . -_._ 14. _ _ _- _._ _ ._ -. 15. C. Physical Evidence: ; 16. 1. Skid Marks___-I.r.D-"7c - _ , ' b8. 19. __. 120. 121. 2. Debr is :RLWST1 C- SC211-L 71."_C=lj_ ?L A-Ern cat-1 r„rtTLN A cOV(P/evt'k!I 22. O't)&LS -fy! 4or -th/ piDA47J-t2- 23- _. _ _. - '25. 26. 3. Other : ".D'J= -- ' 27. - 28. 129. 30.__ - - 131. PREPARERS NAME AND LD NUMBER / DATE -- REVIEWERS NAME _- tDATc 7-<-r-=12 =N 44o7 _ilt .5-2394 -__ i _ ___ - -.__ __.. Use previous editions and depleted. w 5-'54 • STATE OF CALIFORNIA NARRATIVE/SUPPLEMENTAL /- CHP 556(Rev 7-90)OPI 042 Page C J DATE OF INCIDENT/OCCURRENCE ( v� -1-1n. t "� TIME(2400) NCIC NUMBER OFFICER I.D.NUMBER NUMBER 05- 23-1 II4Fn. t238T 19S-op ? >4-O55f. '47/ -,-ONE XONE TYPE SUPPLEMENTAL(X APPLICABLE) ❑Narrative ❑Collision report H BA update ❑Fatal Li Hit and run update ❑Supplemental ❑Other: I C Hazardous materials ❑School bus H Other: CITYICOUNTINJUDICIAL DISTRICT REPORTING DISTRICLSEAT I CITATION NUMBER - -- _ STATE HIGHWAY RELATED LocnnowsueJELT ❑Yes ❑No 1� S i74't�G YntrTTS . .._ - 2. PLe?f.a- 15 . 3. `L- 1 air,4-tD tE 4- S ep t2.1r/v-ZCs -/T� Vrrl.1 Y 2L, . 5. tr- ` -. 1='I L-0)--D c F1C MRS 5- 'F '. ' ALT f7t'c 12-er 6. El 6,44-9- ro€ - F/15 cJetvrL-. 1- SA-t/0 771- Tr2PrTL c 7. L((n ri-r- S i ft`!"-T) die D 7Dt A-- Ye a...Y. tD- $ Tr✓r1 8. WILLI.Lr o -r rt A°O raor -n4 3vQNo `r.2AvrL o, 9. T-GK1PLE. 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X31. • R-v --___ � nRERSN M AND D.NOMaER / DA- �! r VIEWER'S NAME DATE ( K(,E r'ceS�t- *1'73 L IOS 23 Use previous editions until depleted. w sod SLTE OF CALIFORNIA NARRATIVE/SUPPLEMENTAL CHP 556(Rev 7-90)OPI 042 - _ Page - DATEOFINCIDENT)OcCURRENCE TIME(24oe) NCC NUMBER OFFCEH I.D.NUMBER NUMBER Ds-23- / S ,Ltoo t90C `4,7, 11 Iflv79'75'- on) - Cr?/ -CONE 'x'ONE TYPE SUPPLEMENTAL rr APPLICABLE) ❑Narrative ❑Collision report ❑BA update ❑Fatal ❑Hu and run update ❑Supplemental ❑Other: ❑Hazardous materials ❑School bus ❑Other I CITY/COUNTY/JUDICIAL DPTRCT REPORTING DISTRICT/BEAT CRATON NUMBER L( ATIOWSUBJECT STATE HIGHWAY RELATED ❑Yes ❑No -'- 12- ,-172-r"'JAI m-eVDAertcyzS 2. 3. NOr-J 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 123. 24. I 25.26. 27. 28. 29. 30. 31. DATE PREPARERS IS-reT2.�MSR Q '3 .c+t' ,ps-2SREVIEWERSNAMEDATE Use previous editions until depleted- m 51541 771 tc 09— STATE OF CALIFORNIA ri III 41- k- 50998I105C4 CERTIFICATE OF TITLE -c-1AUTOMOBILE -' Po MBEs �'�"„ 1962 CHEV man REGIS-RAI-10h ,SV hi}j 209274263675 Upll„lit1 n. _- a, UN.Lr'' p , r_ES MC : am.,TON DKK: 41 ititO ViNti CP 6 10/16/98 $80 01/12/2000 X1111 tffb IR P . - .. s HUMBER ISSUE DAT. ,�v - a'. ” 1962 AC 1998 DY 11/15/98 J �..,..n =LC-EP WI Joo AZTER .oeu c—_–.1r-3 go, LAWHORN THOMAS MICHAEL SR $ c• i ti 4837 N WILLMONTE AVE ^7; 94; TEMPLE CITY CA 91780 - eft ill j j Ounder penally of perjury under Ina laws or Ice :ao a o s. hat SIG SURE(S)BELOW RP CASES INTEREST INI:HE VEHICLE . j , �A'I�I,i X '101w a qAIO I�nI T t_ step o w INI � 0 e r al a State la thatyoustale themileage pontransfer ofownership Failure to complete or providing aillg falsestatementm2 s tines 2 Isimprisonment 1 Theodometer now a ' 1 t to is toInc best of my knowledge reflects the acral leaste unless oneof t following s is h_:ke. I tsterl WARNING El Doometer rcasinzi iz,^ tne ertal mileade 0 Mileagt exceedshne odometern ll as. jl I certify under penally of perjury under the laws of the State of California!hal the forego ng is true and correct. P,r.a..,, J1ei +1 '.. yet su-�,....�.. Y. I,'' Wulnjl,, -,,. ,,,,„ a% \ IMPORTANT READ CAREFULLY wN 1 Any change o'Lie n Ides(hopes of se.,ur`y interest) ust he reported to the Depermen:of Motor Vehisies within tie '3 caysVS 2- S`gnature re eases interest r ven sle.IComoany _-- �s G I names musbe countersigned) Q -1 Release Dale Zil �' iii CA 36261381 II 004330 =-G Bole 299j O -.11111Ij�i _ IdlI11 �: " y tis KEEP IN A SAFE PLACE VOID IF ALTERED ? 'I . z : ���'�_� September 9, 1999 RECErkWE1? CITY n= SEP 13 1999 TO: City of Rosemead CITY CLERK'S OFFICE ATTENTION: Nancy Valderrama, City Clerk RE: Claim Kyborz v. City of Rosemead Claimant John Leroy Kyborz D/Event 23-May-99 Rec'd Y/Office : 02-Sep-99 Our File S-101361-SWQ We have reviewed the above captioned claim and request that you take the action indicated below: • CLAIM REJECTION: Send a standard rejection letter to the claimant. Please provide us with a copy of the notice sent, as requested above. If you have any questions please contact the undersigned. Very truly yours, CARL WARREN& COMPANY /Le • 4 Dwight J. Kunz cc: CJPIA Attn: Executive Director CARL WARREN & CO. CLAIMS MANACEMENT.CLAIMS ADJUSTERS 750 The City Drive•Ste 400•Orange,CA 92868 Mail:P.O. Box 25180•Santa Ana,Ca 92799-5180 Phone' (7141)G0-M99 FN lane rRnn)en-Fenn.Po.-('IA'ianono Ants City of Rosemead L 8838 E.Valley Boulevard Rosemead,CA 91770-1559 Telephone: (626)288-6671 Fax: (626) 307-9218 Mayor Joe Vasquez Mayor Pro Tern Margaret Clark Councilmanbers Robert Bruesch Jay Imperial . Gary Taylor Fax Transmission Cover Sheet Fax #: 714 740-9412 To: Steve White—Carl Warren & Co. From: Nancy Valderrama, City Clerk Date: September 16, 1999 Re: John Kyborz Claim— S 101361 SWQ You should receive 2 page(s), including this cover sheet. If you do not receive all the pages, please call(626) 288-6671. Mr. Kyborz just turned in the following estimate for repairs to his vehicle. ESTIMATE of CHARGES -ZrIII _ _ I ty 1' Vit ►1 r 1 lit 43114/4 i 'moi` ;/t0Stay" aicra 9436 Las Tunas Drive Temple City, CA 91780 - (626) 287-2404 Name - Sena' r is. / u�_ /ss. _ Address Year a 62 Ins Cc City Mfel Phone Licence Color I REPAIR REPLACE DETAILS LABOR LABOR SUBLET d HOURS AMOUNT PARIS MATERIALS it 1 •• i / —_ � e 1-4; --- 1 Cil" 5 25 ///a/c--• - F • Asa • • TOTALS Complete Body and Fender Repair and Painting Labor Foreign and Domestic—Insurance Work Pans Frame Straightening—Specializing in Unibody ------ Mig Welding—Fiberglass Repair - Materials This estimate Ls based' on our inspection and does not cover additional parts or labor which may be required Sublet atter the work has been started.After the work has started.worn or damaged parts which are not evident on first inspection maybe discovered.Naturally thisestimate cannot Neer such contingencies.Pans prices subject to change without notice.This estimate is for immediate acceptance Tax Above work Advance Chames Authorized by Date �2 GRAND TOTAL Estimated by nate �(>{'7 / RECEIVED CITY OF FOSE MEAD JJJ SEP 1 71999 Li �J7 ° CITY CLERK'S OFFICE GO RNMENTAL ENTITY PRELIMINARY REPORT TO:Carl W en& Company DATE: 09/10/99 750 e City Drive, Suite 400 CLAIMANT: John Kyborz O'• ge, CA 92868 FILE NO: S 101361 SWQ ttn: Richard Mar•ue D VENT: 5-23-99 FILING DATE: 9-2-99 SIX MOS.: YES PRINCIPAL/CITY: CJPIA/City of Rosemead RECOMMENDED ACTION ON CLAIM: Rejection. FACTS: The claimant was involved in a motor vehicle accident. He has alleged that the collision occurred because the traffic signal lights were not functioning properly. POSSIBLE CO-DEFENDANTS: Peek Traffic /Signal Maintenance, Inc. EVALUATION: We will tender claim to co-defendant. RESERVES TYPE OF CLAIM AMOUNT 1. John Kvborz LPD $5.000.00 COMMENT/WORK TO BE COMPLETED: Our further report will follow shortly. Very truly yours, CA WARREN & COMPANY Stephen A. White ISIt-c: City of Rosemead, Attn. Nancy Valderrama cc: CJPIA - Attn.: Executive Director CARL WARREN & CO. CLAIMS MANACEMENT.CLAIMS ADJUSTERS 750 The City Drive•Ste 400•Orange,GA 92868 Mail: PO.Box 25180•Santa Ana,Ca 92799-5180 ...___. ,...,..,. _,oflfl '• colV -C,...nia,van-anrr