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P.:tachments Disu:�ut'_cn Co: <br /> - .�'roi �ce Reco_t Cl�im `or Oanages =or� �co�t ,ve:z=1 <br /> �ision Repo=[ _ +! j� �,S - � ', Ris� Nanao=r _ <br /> Gther Ce�t. Coce �1 <br /> � R I �eot Neaa's vsme <br /> v �wA'�--� U I�✓ �eot Head's ?!� <br /> 9 s6s � � <br /> � Pub ic Utility District l�o. 1 <br /> � Please take notice, that of Snohor�iish Countv , �no resides <br /> I at 2320 California Street, Everett, llashinoton , tzlephone 31258-8211 , <br /> � work phone !i and wno for six �nonths prior to Cne occurrence <br /> � resided at same claims damages of and from the <br /> City of Everett in the sum of 34,742.20 arising out oY the followino circumstances <br /> listed helow: <br /> DAY/TIME OF OCCURRENCE: June 18, 1983, at approximately 11 :00 p.m. <br /> 1 LOCATION OF OCCURRENCc: 2320 California Street, Everett <br /> IDESCRIPTION: <br /> 1. Describe occurrence explaining the nature of the defects or acts <br /> of negligence causing damages. <br /> �. Provide itemized listing of all expenses, injuries, and losses � <br /> ` and attach copies of estimate or bills. m <br /> ' l.� 3. Provide a list of witnesses to the occurrence including names, <br /> n addresses, and phone numbers. + � <br /> � "� � � <br /> � The City of Everett sewer system backed up, causing ti;ater to back up o m <br /> " into the Uistrict's office building. This caused damage to carpet, custoner m o <br /> b�llin forms, and loosenin of floor tiles. 0 3 <br /> g g (Iter�ized billing attached. ) ,., <br /> -� z <br /> x1 <br /> m <br /> .. <br /> i , q Z <br /> i D 1 <br /> o-r. ..2. <br /> 1 --1 N <br /> < <br /> �'I <br /> O Aa <br /> T 3 <br /> -� m <br /> x <br /> m � <br /> N <br /> Attach an extra sheet for additional information as needed) o r <br /> t� m <br /> C N <br /> Additional Information ReGuired for AUTOMOBILE CLAIMS ONLY Z � <br /> —r r <br /> �icense Plate No: Driver License No. : n <br /> � <br /> � Type Auto: _ <br /> ; (year) . (make) (model) i <br /> ` ORIVER: • OWNER: i <br /> � <br /> � Address: Address: _ <br /> , <br /> l � <br /> -� <br /> � <br /> Phone Il: Phone ll: `^ <br /> PASSENGERS: <br /> Name: ��ame: <br /> Address: Address� <br /> I . .-- <br /> + OtvNERS Insurance Co. & Policy No._ <br /> : I, ti: I;. Stevenson , being first duly sworn, tleposa and say <br /> that I am the claimant abo�a described; that I have read the above claim, know the <br /> � conterts tr�ereof and believe the same to be true. <br /> � <br /> ' SUB�i.R79ED and � CRN to befot� me this /� > � <br /> � �/� � �� <br /> 1 fl�'_�!�y uf V � '7/ •�.�£1.� , 19 c'� ///•/✓ S �c'.C.'G1,' C!L21,' <br /> t ..( ti`-l_. ) / / � / / <br /> I �ir� �� <br /> / <br /> ...i{�ii-.i ✓!l�J'yi�(.�'�✓ <br /> � '.�CTARY FUELIC in an for theC /S/tate of Washington <br /> "��c°,�<<,�.z�-�. �f �• - �` <br />