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HomeMy WebLinkAbout02-08-2017 Leeper, Jack - Claim for Damages (rec'd 2-14-2017)F- 8o2498/2°17 @2:3"7 PM pig;Rfsof t€01702080017 i,ill,i]T,hal,iiiii[ii!iiifffiiiiiiiii(iiiiiiiiii]iiili!Iiiiiiiiiilll!l!'`!']'!!! jROsEeuroR Prose8u€® rs Cffiee FEB fl 4 2®i7 Civil Divisl®m tT:Hrf comassloNERs|±4_i DEPA:i.TT.J:I,`JT#yi'=\`±=. I,\~`' Tut If`--. L> = 1-. KITTITAS COUNTY CLAIM FOR DAMAGES Return to: :o°5u#5A|dv£::;uitel05 Ellensburg, WA 98926 509-962-7504 Instructions: Please read the entire form before completion. Fill out each question as completely as possible, to the best of your ability. Do not hesitate to use the back side of this fom if you need more than the space provided. An incomplete response may delay the processing of your claim. 1. Name (Including spouse, if married):i_B±±__LceT|f± Phone (hTome):4±1ft__lEi Address (include former address if at present address for less than 6 months): | IC) S~oQutLch /G DR. €noQu^ru~ii£_ f:4€J. ut 98o€8' Physical ©to\ BBldcMltr Rd El(ErJSBuf26r wh 96¥26 Mailing DateofBirth: 9~/~G/ 5. Date and Time of lncident:r tc)- 7Lo\ Location of Incident: 7`o sr`c>QUAL vw`Er 1of3 Kittitas County Claim for Damages Form Revised 9/2012 i 4 7. Describe in detail the defect which caused the injury: 1<14AAS CO S1UOW feMOI%A-( Slowe-fL wis e4yeJE,> V1'1�1 b0vnt z C4 +n J)e 14f4,t 4•i•�D�r_� _ OT -5-naw 8. Describe in narrative formandand in detail exactly how the incident occurred: r �O--%) LA-Prf [ r re c.'i� G3 � bol✓ a,^ Go 07 µ o w 9. List the names of all persons involved and contact information, if known. L4 N K(A o c—j O.J 10. Was claim investigated by a police officer? AP6 Sheiiff tate Patrol City Police 11. Description of claimant's vehicle: Make Year Model: License No. 12. Describe what you did after the accident occurred: SR+- Ann Ie4 VnegJ ars i c-+ Th 're.,AJ Fo�E.,.,�►,� fd 13. Describe the conversations you had, if any, with County personnel during or after the incident occurred: 2 of 3 Kittitas County Claim for Damages Form Revised 9/2012 14. Desc90"'al"t" be the damages or injuries 'which you sustained as a result of the incident: .r'�a".S. W�n�w ❑arcs ser. NVQA�•,.w L>Oov-. `�✓1 C7 r OuJ f t►,4 �c] &;o C�V I T•,% I I 8 �d�3� S ��S �7c� C) Rah ��•-Y, 15. What is the amount of damages claimed? (Include estimates and bills, if available): (: Se xtP�. f = 89 z.08 p rA 100, 0 _ UO"tLwtNofl- 4 1o�Lq. O �;-x'00 `'�AL->okos�43 16. How did you identify the County as the parry responsible for your damage? COMA J SMe'L-J ✓enaa un.1 IT List the names and addresses of all witnesses to the incident: N en[ 18. Are you covered by insurance? Ye5 If yes, who is your insurance agent/carrier? f nr 2G M oST" �nS�t�ANL E � �ou� Dated this _ Day of �� 0 _, 20�. Siana of C ant Subscribed and sworn (affirmed) to before me this day of (-" ELV4 u/ , 2019 NOWY PWAC Still d WOMMPI fift T Uri My Appolnlmrdt EKOq JUN K MO 3 of 3 Kittitas County Claim for Damages Form Revised 912012 Notary Public in and for the State of Washington Residing at 3 of 3 Kittitas County Claim for Damages Form Revised 912012 Paint & Floor Covering 610 South Main ° P.O. Box 1238 Ellensburg, WA 98926-1238 Phone (509) 962-2551 Fax (509) 925-5855 PROPOSAL AND ACCEPTANCE PROPOSAL SUBMITTED TO c � �e fr PHONE DATE 25— ve/`/ _Ar 2/S/1-7 STREET 710 ✓R. /r1 2 �r JOB NAME CITY, STATE AND ZIP CODE S4 o JOB LOCATION SALESPERS _ OC1 rte\ JOB1 6 5 .�q We hereby submit specifications and estimates for: T� t$�l R n SLC CW~ SCO 3'Z`8 w 1 �5 re► .c� d i n 6,le- h aArv& M e $ 'X 10 ` - VAVC4- cane_s roIts . We Propose hereby to furnish material and labor - complete in e^ p + "a Z --doilars accordance with above specifications, for the sum of: f ll[$ 0 7 J °y Payment Method: 0 Cash 0 Check 0 Charge/Acct # 0 Deposit Amount �L 0 Bank Card # Exp. Date Balance Due on Completiori All material is guaranteed to be as specified. All work to be completed in a workmanlike manner according to standard practices. Any alteration or deviation from above specifications involving extra costs will be executed only upon written orders, and will become an extra charge over and above the estimate. All agreements contingent upon strikes, accidents, or delays beyond our control. Owner to carry fire, tornado, and other necessary insurance. Our workers are fully covered by Workman's Compensation insurance. We look forward to working with you on your project. As a result of a change in the law by the Washington State Legislature, the following notice Is required to be sent to all our customers covered by the revised law. If at any time during the project you are not completely satisfied, we hope that you will contact us Immediately. The law requires we advise you of the following: NOTICE TO CUSTOMERS This contractor is registered with the state of Washington as a general specialty contractor, PREMIPF953RT, and has posted with the state a bond or cash deposit of $6,000.00/$4,000.00 for Authorized the purpose of satisfying claims against the contractor for negligent or improper work or breach of contract in the conduct of the contractor's business. The expiration date of this contractor's registration Signature is . This bond or cash deposit may not be sufficient to cover a claim which might arise from the work done under your contract. If any supplier of materials used in your construction project or any employee of the contractor orsubcontractor is not paid by the contractor or subcontractor Note: This proposal may be withdrawn by us on your job, your property may be liened to force payment. If you wish additional protection, you if not accepted within days. may request the contractor to provide you with further information about lien release documents if you request it. General Information is also available from the Department of Labor and Industries. A late charge of one and one-half percent (1 1/2%) per month, which is an annual percentage rate of 18% interest at the maximum lawful rate, whichever is greater, is charged on all past due accounts. In case action is brought to collect this account, I consent to jurisdiction of and service of process by the courts and agree venue may be laid in the state of Washington, County of Kittitas; and that the action may be maintained without regard to the residence of defendants. In any action brought to collect this account, I will pay such sum as the court may adjudge reasonable as the court may adjudge reasonable as attorney's fees and costs. Acceptance of Proposal The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Payment will be made as outlined above. Date ._____. _. Signature Title Please sign and return white (original) copy. Leeper Res....,...... February 1, 2017 Ron Linde�'rCJ t�I C #g% Laconia Builders 119 POB 22 Snoqualmie Pass, WA 98068 Mobile 425-214-3973 ronlinde@hotmail.com Project Customer Leeper Residence Jack Leeper Mobile (425) 444-1875 ski@hyak.net http://Hyak.net Repair damage caused by Kittitas County snowplow �ve�wtption Z, —.:;:y - Naurs -..,...�rial LAW Cuter subcontrad co tm Interior Trim 930.00 - - '-J ::!n::!:1! lrasrior and exterior window trim 1 Ea 3.5 150.00 210.00 0.00 0.00 360.00 Repla;,; 2 2-40.00. 120Xx- O.OG O.OG 360.0_ Remove broken window and Install new window, flashing, Replace Interior door 1 Ea 2.5 60.00 150.00 0.00 0.00 210.00 door, mount hinges and lock set Project Subtotal 8 450.00 480.00 0.00 0.00 930.00 Fixed Fee 50.00 Project. T: -z' 8 W- --� --- Tax 38:40 Total with Tax 1,018.40 e^^rl ved By: Date: Date, Contractor Customer Laconia Builders 1 ¢/ k �" � �� �' n � al 0 � oM cY IA "I AA ii. .r ipti ft 0 F % hA�" N k lk 4 4 7-0 7rk jimm � .. - - -.- w Amb, f 1 i I; I 10, o0a t - t ft P, u •SI W w ,J i ' f W w A -e j I t- t r"PPPPP r { • r- �..�.. �� .rte � • # I •l s 0 14 qf IL m - '.1111t1l1l1llil;li It 11 (5 .OW lk IN, Ile qr d, 10 l6d vo 10. "m roe AIP ;7A