7811 GRANT DR B 2022-05-24 - Laserfiche WebLink

.Ile,Io5- 0 .E elP".., -A REYeE%, \ ,� TDRT CLAIM FORM NOV 0 1 2013 Rev.07/09 CITY OF EVERETT Pursuant to Chapter 4.96 of the Reevised Code of Washington (RCW), City Clerk this form is for filing a tort claim against the City of Everett. Some of the information requested on this form Is required by RCW 4.96.020 and may be subject to public disclosure. The City Clerk is the City's City Clerk Claim No. designated agent for the purpose of receiving claims. Claim forms i), id ^ 1 cannot be submitted electronically(via e-mail or fax). GCaot3oo442(p 104$9 rtP*Ok PnNT 6.lEA10 IN.xNrt Mail or deliver original signed claim form to: Office of the City Clerk City of Everett Business Hours: 2930 Wetmore Ave.,Ste. 1-A Mon.—Fri.,8 a.m.to 5 p.m.,Pacific Time Everett,WA 98201 Closed on city holidays CLAIMANT INFORMATION: 1.Claimant's name: r .neat nailer Vi1"omg. f Y�' Last�3'iame � I�"�r?' ��! �' �flist i Middle Date of birth(mm/ddjyyyy) • fir 2 t 2.Current residential address: J tl ,. 5 61,i-a i t i < )t{�t y I''r" v.( r•(n. i-I( , q,2 1 et j r r� 1 r i 3. Mailing address(if different) 7 `. v (/1/1 fl ,.fit f4.�.;-,`•d,'�1) c1'1t'11): l 1W (742(/o 4. Residential 1 addressi at the time of the incident(if different from current address): f / at. q iI 1 'i 'D 1- . Ss:'•' sc 1)Oh:-}l, I 1,Si i t 1?ii'1 ' }',a 470 5.Claimant's telephone number: "— 4 ti ) :to. t I .i/II Home , 6.Claimant's e-mail address: 'i i)'ti 4 E__("\ P:}"i1 a t 1( i t-4 ."1:0 Ft;t'i'd ►y j(�: Business INCIDENT INFORMATION: ' 7.Date of Incident: 0 t( / ,11 .' ),� Time : r''0() (nim/dd/yyyy) ❑a•m..;l p.m. (check one) 8.If the incident occurred ove period of time,date of first and last occurrences: frown:0 /g l ail 4 Time: r 0 a.m. 0 p.m.(check one) UR/12 OR Time: ; 0 a.m. 0 p.m.(check one) (tnrhAl/Myyy) t0 WI 'i 1,4 I) (mm/ d/YWY) 'r ),,' .., �/ ,�t � c�� 1 �tJit t 9. Location of Incident: \1IA 1 �`> 0 )I NII I)'As ► ! , . , ' - " v t e1 }`��f,y� ��`".�'> ('f� ?.t.li��,1,)� a �llr� �.�;r.6'i State and county City,If app//cable P/ace where occurred( irt- refl.t 10.If the Incident occurred on a street or highway:, 5 i t .42 ) 11 'e l) key P }i{`''#, 1 ' •) '" .—,k. ')-' k t ; Name ofstreet or'hi highway. t' �n Q y At the/rrtersecdorl w/lh orneareatln ersetdng street Rev.07109