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����i� �;' � �_ � --i �'- 1-:�'�"�`•', <br />�«�.o�io9 <br />Pursoant to Chapter q.9G of the Revlsed Cade of Washington (RCW), <br />� this form Is for flling a tort clalm agalnst tho Clty af Everett. Some of <br />lhe Informallnn requested on lhls form Is reqolrcd by RCW 4.96.020 <br />' and may bc subJed tn pu611c cllsdosurc. lhe Clty Cled< Is Iha Gry's <br />deslgnated agent for lhe purpose of recelving clalms. ClaGn Fonnr <br />� cannat Ln subm/tted e%ctronlca!ly (v/e e-map a• fa�Q. <br />a <br />.�.��.�����a�i <br />SEP 18 2013 <br />��xx o� �v��,Ex� <br />City C'lcr.k <br />CIIyG1e�kClalmNo. - I <br />�� �6"3-13 <br />PLFJISETYPE'OR•V[tINY�CLFARLY'dNjI1�11( -,;:; : :.c..i . . .... . . , : _.: : <br />Mail or Aellver original signeJ claim forni to: <br />Business Hours: <br />Mon. — Fd.� 8 a.m. to 5 p.m„ PaciFic Time <br />qoeed on clty holtday@ <br />CLQiMANTINFOHMATION: <br />i, Clalmant's name: <br />oHice of the City Clerk <br />City oP Evetett <br />2930 Wohnore Ave., Ste. l-A <br />Everett, WA 88201 <br />Zv//9S—Z— <br />Cast name Nrsr rnoaie �am aqmrtn (m'rpauiriri7 <br />2.Nrre�tresldenUaladdress: �?2 �l�71� %7L �,1/. /Z'!G/(G��o� jN.4� '�'t SZ%}' <br />3. Malling address (If dlfferent): <br />4. Resldentlal oddress at the ttme of the Incident (IF different from cutrent address): <br />5. Clalmant's lelephone number: �zS -��S'7!� 'r't Kx� '��_�rzz <br />Nome Ccll _Llluslness <br />6, Clalmant', e-mall address: /'�lG�Q�"�' 2 0 �F eo^. Ci+� �'�✓� � <br />jNCIDEMT IPI�ORMATIOtd: <br />O Zr7 ZlJf �3� ��� <br />7. Date of IncldenL• � 71me: 5 ❑�,m. L N' p.m, (checl<one) <br />(mm/dd/ ) <br />8. [f the Incldent occurred over a pedod of tlme, dale of Ilrst and last occurrences: <br />fiam: iimo: ❑ a.m. f.l p.m. (chedc ona) lo Time; ❑ nm. fl p.m. (check one) <br />(mMJdIYVVY) (mnd�e/YV✓V) <br />9. I.ocatlon of InddenL' �Q Na _ it.�f ���'7?�tT S 7�'� C aL� vj <br />state nd rounh� �Ty, llappJlwWc Flacti where arnrred <br />10, If the Incident occurred on a street or hlgh�vay: <br />Name olsheet arh/ahn:ry At the /nlrrercNan wlth orneamst Inhvs2rHng snce! <br />Rov. Oif08 <br />� /� <br />0 <br />0 <br />