4917 SEAVIEW WAY 2022-05-31 - Laserfiche WebLink

, City of Everett Use Only RECEIVED - k .s, R ;, a. M .� • SEP 13 2013 Rev.07/09 Pursuant to Chapter 4.96 of ti ,{evisecP ie Hof--Washington (RCW), CITY OF EVERE' ` this form is for filing a tort`ottar'rwagainst'the.City nft.Everett Some of the information requested.n this:Join i::fstrequirecFby RC11V 4.96.020 city Clerk Claim Nd �.. and may be subject to public dlisdostute - e:`.City=Cierk<is the City's - designated agent for the'porpose:of.t l ` airns• - laim halms i.r k -e cannot be su6mitted+electinr�ir 'l fviamaifrsrax . • e•0J-6Q 014dl 4, PLEASE TYPE OR PRINT ARL7T1C - 2Office of the City Clerk Mail or deliver ar�g9nat;�neci. fii��qy,tta .i .Lily of Everett Business Hours: I, ,ar'.i<93O Wetmore Ave.,Ste.1-A Mon...--Fri.,8 a.m.to.5• t ttr.,PacdfiC 3'ame 3."'-,, :fverett,WA 98201 Closed on city holidays - CLAIMANT INFORMATION. {- 1.Claimant's name: Ca.I p be 1I :fin .05 • — 091 17129 Last name ',. Hrst - Middle Date of birth(mm/dd/yyw) 2.Current residential address: 7 et,/tit w ,>1 Sat-; ti-t_..(!'ii�_—i — J 3.Mailing address(if different): _- • _—: _.-__.____. 4.Residential address at thetime of'the'incident=(if different from current address): 5.Claimant's telephone number: S/ -.S 3 y 7- L/1/0 r' t�- y ' 7 7 Ho Cell T3usfness 6.Claimant's a-mail address: St)s 1 2.n+r/'''� O I i CO✓h _----•---_______--- INCIDENT INFORMATION: 7.Date of Incident; / L Time: _.._.,—_._—_ 0 a.m, 0p.m. (check one) };(mm/dd/i 8.If the incident occurred:aver.a.period of time,<date of first and last occurrences: from: Time: • .•D•a.m. lIp:m.-(check one) to._.. Time: _ IJ a.m. Ll p.m`.(check one) (inm/dd/yyyy) (mm/dd/wYY) 9. Location of incident: 1/?i'7•,`S r,e ` (VA v Ere -e+ ._ 51cte..+_Sti— .State.andcnunty City,if applicable Place where occurreii 10,:If the incident occurred on-a street•oa`tl ighway: Name of street or highway At flie intersection Ott yr nearest intersecting strut Rev.07t09 1