3615 MCDOUGALL AVE EVERETT DOWNTOWN STORAGE 2022-05-26

n ToRt CLAIM FDRM Rev. 07/09 Pursuant to Chapter 4.96 of the Revised Code of Washington (RCW), 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: designatedagent for the purpose of receiving claims. Claim forms cannot be submitted electronically (via e-mail or fax), City of Everett Use Only RECEIVE'"D SEP 19 2013 CITY OF EVERE TT UtE Clerk City Glerk Claim No. —1 &Cajo130 C.) 4/.5av �--- .. yr _r. -.._:. _ . v._t., w•»�,-... Y__........a.., � x .a—... ^ne 5v'� r.. :'�E�...«fo 1. ?ki n �.` it.+. - .4'n.2k' n3x.e J:C:�i: SiFh�.iJ�#w.. r. a �,. Mail or deliver' original signed claim form to: Office of the City Clerk City of Everett Business Hours: 2930 Wetmore Ave., Stet -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: J�-Vare-tf Pa+xs3ltoUu"L 5'firCLg-9— S ors A T' 06 /0, Lastname First M/ddle Date of birth Fm dd/yyyy) 2. Current residential address: , 3615 io-- E-VI-14l '70.2 1 3. Mailing address (if different): '- Ca -0cw Poyatf 1 bzvro 4. Residential address at the time of the Incident (if different from current address). t-i CA S. Claimant's telephone number: �� `' S� t' a �Z 5, 303 , 0'3'141 Home Cel! Business 6. Claimant's e-mail' address: S t�VP-rs �' V f 1 Qwtf`lvu_sry 5 fvr tct , c� ivi INCIDENT INFORMATION: 7. Date of Incident:, ce `Z`� p 13 Time : ❑ a.m. Xp.m. (check one) (m /ddlyyyy) 8. If the Incident occurred over a period of time, date' of first and last occurrences: from: Time: ❑ a.m. 0 p.m. (check one) to Time: Dim. ❑ p.m. (check one) (mm/dd/yM) (mm/ddlY'") �.. 9. Location of Incident: w � ) s li o�©F"ht'J� C-Ji1'r 3616 (0cDt7v Co ke State and county CYty, It appl/cab/e Place where occur ed 10. If the Incident occurred on a street or highway: Name ofstreet or highway Rev. 07/09` 36" S -to 37'