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-- --- --- --- -- - --- - --- -- <br /> - - - - - -- --- <br /> I <br /> Rc����IV�D � - <br /> _ _ _ . _ _ _ � <br /> Ev TORT CLAdM FOR/►9 SEP o 6 2013 I <br /> N��.0��09 �. <br /> Pursuant to Chaptcr h.9G of thc Revl,ed Cotle of Washingron (RCW), C1'�Y OF EVERE'�"P ! <br /> lhis form is for Ning a [ort clalm agalnst the City oF[verelt. Some nf C�E' Clerlr, � <br /> - Ihr. Infonnation requested on this form Is required by RCW 4.96.020 <br /> and may be subJect to publlc disdosure. 71ie City Cle�k Is lhe City's Cily Ltork Cla!mNa. �7 <br /> deslgnated agent for Ihe purposc of recelving dalm=. C1.3lm fornn �Qa--— I 'J <br /> cannofbesuGmiKedelectronhally(vlae-ma//vrfaxJ. . �U� L 3 � <br /> ... ..._ . . ... . _ ... ... , , . <br /> jPLEA§E�7YPEORPf�IN.T�GLEARLYi.INYNK „ �.;�; - y ���-�_.�._ ._.__ .___ ..-.__ ' __:''� I <br /> Mail or deliver oYiginai signed clafm form to: ffieo of the Clty Clerk � <br /> City of Evcrett � <br /> Business Hours: 2930 Wetmora Ave.,Ste. - <br /> Mon.—Fri.,8 a.m.to 5 p.m.,Pacific Time Everett,WA 98201 <br /> Clased on city holidays <br /> CLAIMANT INFORMATION: <br /> I. almant's namc: <br /> ' ,������.���-�-' ' _r� � �s'� <br /> [�s �,3� F/rsf Afl !e afc o/GMh(mrlp'd,/}yyy) <br /> ��j��' /,/ D� <br /> 2.CuRentresidentialaddress: �:�e�lJ�--lN� � <br /> 3.t4alling addtrss(if diffcrent): — <br /> 4.Residential address a[tlie Ume of the InQdent(If dlfferent from current address); <br /> 5. Clalinant's telephonc numhe�: __ �� � •�✓/-- — <br /> � Hnme • Cdl Buslness . <br /> G.Clalmant's c-mall address: _..��,�P� — n <br /> Q/ /�2 /� �.Q��, �<E Orl Lt�C�'. <br /> aNCIDFNTINFORMATION: QL� p8/Q�' QX�lX.� �%od�om . <br /> Q �/ ? <br /> 7. Uate of Inddent: FJ����� 17me: _. L]a.m.�.ni. (check onr.) <br /> (mi dJlyYyy) <br /> H.If the I tiden[qnccui2red o`vter a pei lod of time,da[e o(firt anA las[ocnrr nces: <br /> from:��0�,�+Ime7_ )U 0 n.m.�p.m.(check one) to����(i�_UO 0 a.m, �m.(check one) <br /> (mmJddlri'ri) ' . (mnddd/yyyy) • " � <br /> 9.Locaqon of IndAe�t:w `�� - ✓�7=-�'`�1��/ ' �12t� ��–��.-��-//�vr� <br /> SG�te and rnunry CiQ:l/app9o�ble Place Hhere ocrmred . <br /> 10.If Uie hiddenl ocr'�qed on a street or hlghway: G�, � / <br /> "`^`--"–Namca�shYCfnr/a�Airay � A�fhefn7emWuu�lfhwn^amstln!ersrctin95(rcef <br /> Rev.U7109 <br /> �V <br /> I <br />