2820 OAKES AVE AUSTIN BAR AND GRILL 2022-05-26

, . City of Everett Use Only , "Op 4E: = EIVE • TORT CLAIM FORM Rev.07/09 OCT 2 9 21113 Pursuant to Chapter 4.96 of the Revised Code of Washington (RCW), CITY OF EVERETT this form is for thing a tort claim against the City of Everett. Some of the information requested on this form is required by RCW 4.96.020 City Clerk and may be subject to public disclosure. The City Clerk is the OWE City Clerk Cial50‘No. designated agent for the purpose of receiving claims. Claim farms 1-7 — cannot ha submitted electronically(via e-mail or fax). C vd" 1300416011 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. aalmanes name: c.-1 Kt\\t) Last name first Middle Date of birth(pin/cIWYWY) 2, Current residential address: 2-- ao Av L I-TT (l'A IN- 9i z-0 1 3. Mailing address(if different): 4. Residential address at the time of the incident(if different from current address): 5. Claimant's telephone number: t?- 1Z---6622-1 -3 12-1 zrK.S r\FR Y I 40t) C Cell 6. Claimant's e-mail address: - *c 0 Business INCIDENT INFORMATION: kvtq 7. Date of incident: —21r 1 Time : El a.m. K.m. (check one) (mm/dd/yyyy) 8. If the incident occurred over a period of time,date of first and last2ccurrences: from: 8e-M-1.)7 Time: 0 a.m. 0 p.m.(check one) to (-1'1 '15 Time: 0 a.m. 0 p.m.(check one) (mm/dd/yyyy) (mm/dd/yyyy) 9. Location of incident: A.}0/)0 Mil 14 gvkUVI- 74k_ kuSiir\-) State an county City,if applicable , Place where occurred 10. If the incident occurred on a street or highway: 6AKE5 Ck.UFDki tAt kc4--9 Name of street or highway At the Intersection with or neares t-Intersecting street Rev.07/09