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1 <br /> , , (71y01EV0(OMU60Ooly � , <br /> �. . � � . _ �rM o M REC'EIVE� �� . <br /> TORT C f' K <br /> Pev.07/C9 SEP O 9 �U�a '. <br /> Pursuant to Chaptcr 4.9G of thc Rcvlsed Code o`Washingten (RM'), � <br /> this form Is for 81ing a tort daim against the City of Evemtt. Some of ; CdTY O.F F����'J"r �� � <br /> Ihe informa[ion requested an this fotn Is required by RCbV M1.96�020 � <br /> and may be subJeR to public dlsclos.ue. The Ciry Clerk is the City's c�ryaer,oai uo �° - ' " <br /> �Aes!9nated agenl for the purpose ot recelving clalms. C/aim lorms - � � ; <br /> cannotbesuF,mikedeledronlcally(viae-msi/or/ax). I�II C� -_ �7 <br /> — GC.a0�3sio �y6 � <br /> _ � <br /> il'LEASE_T1?P,E�OR�PNTNTCLENNhLtY�:Ndf'I.k�.� .. �'=Tk�. .. ��"� , - ?� > � . . :'r. t� .. r .�,�j � <br /> �l`�.�'� . Y . .Is.af�n'. <br /> I <br /> Mail or deliver orlginal signed cla;:n Torm to: O�ce of tha City Clerk � <br /> City oF Everett � � <br /> Business Hours: 2930 Wetmore Ave„Ste. i-A ' <br /> Mon.-Frf.,8 a.m.to 5 p.m.,Pacific Time Everott,WA 98201 � <br /> Closed on eity holidays � <br /> i <br /> CUUMANTINFORMATION: �• � <br /> i`Claima(�Cs name: ` ` 1� � <br /> JQ.(:QI�JOY1 r �:OUi.C�' ��UY�f� �7- �� '" 'TC� � <br /> �a.ay'L/�.tvr�.,a_ c�S f-1lbC:�-�- - - I �-1 ��T.���--_ <br /> Cusinamc —"�� Hrsi Al,'defe Dafea/C/rth(mir�/dA/yyyyJ . <br /> 2.Curren[resldentialaddress; ����i�`��(,����__,_ <br /> 3.Malling address(IF dlHen:nt): ^7�e-- ___,_ , I <br /> 4.Resfdenlial addicss at lhc Ume of lhe Incident(If dilfcrmt fmm current adJress): � <br /> . . . .. . - _ . � — "---7�1��.--_..—. _ .. . . -�—_. . <br /> u.Claimanl's lclephone numher:��,_���.�.;,-�eL..n1:� �L��L�..�2.������ ..��..__�____ . <br /> p!/�v�e feA � Ousine.c; <br /> G.Clalmanl's c•mall addr�ss: ,�.I1I/��_ �,�. _ ' <br /> If�CIDFNT.INFORMqTiON: <br /> 7,Dalc of Incident: �,r�:1��.-.1.�___rTti� r , � <br /> Timc; �,:�."7 ❑a,m.}�f�p.m. (check ono) j <br /> (mmfddlWrY) � <br /> 1 <br /> 0.I(the Incldent occurred over a perlod af time, date of flrst and last.occurrences: � <br /> from: -� rmc:__.Ll a.m. 0 p.m.(check onc) to Timc ❑a.m. CI p.m.(chc�k onc) : <br /> (nim/dJ/yyyy) � (mm/AJIYYYY) ` � <br /> 9.Lowlion of incidctit: � � � . :`�ly-�s.Y""�OD�\S 1'� f �V�P-�C"�l� , <br /> Stale ond co n ry Oh;ifapp�ic�b,'e Plact�vhEM OCLo700 � � � � <br /> i <br /> 10.If theincident occurred on a s[reet or hlgh�vay: � <br /> A'amC otsfrtrl ci h.'gA��Uy �J A((he LCmrdva n4fh o/nN�est/ntrrSect!�y sfrccl ~ � <br />