HomeMy WebLinkAbout11-15-2017 Peebles, Jackie & Matt Claim for DamagesPROSECU TOIL -
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11/15/2017 03:47:56 PM 201711150066
$0.00 Pawl of 8
Claims Against County/rls/miso PROS
Kittitas County Auditor
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KITTITAS COUNTY CLAIM FOR DAMAGES
County Auditor
205 W 5th Ave, Suite 105
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 form if you need more than
the space provided. An incomplete response may delay the processing of your claim.
Namg_fIncluding spouse, if married):
i a:L Peeb Ips
2. Phone (Home): ) (Work): (So9-�loa-7Dd O )
3. Address (include former address if at present address for less than 6 months):
73DL S�Vnai-eu U gagD-k
Physical v -�
Mailing
4. Date of Birth: -7--D-14,9
5. Date and Time of Incident:
iD-(ci - n e 6cl3o
6. Location of Incident: r p
KC -S () " 30-7 W cj-e, n 4—al a -m l
1 of 3
Kittitas County Claim for Damages Form
Revised 9/2012
V Filed for Record 11/15/2017 03:47:58 PM - Kittitas County, WA Auditor -201711150066 Page 2 of 8
7. Describe in detail the defect which caused the injury:
ji)lIY �rym ,z_ o!�E J� ea. -h -o � Ve-hi`G: cs GSCt cion �l L:-,
61
S�2cr1c, UY�r, �1i?""�1'n.G �'ha- ��IV�ySldae i��✓ C�1rnPv pav�Q.l
Imu (ar.
8. Describe in narrative form and in detail exactly how the incident occurred:
I WaS yLaf- ,�reSen7 p w, eSS -�Ke et661 f9i MV Gam iJGtS
a,! aS tiJ tsYk, rt,�,
9. List the names of all persons involved and contact information, if known.
10. Was claim investigated by a police officer? Ye 5
Sheriff( State Patrol City Police
11. Description of claimant's vehicle: Do ria -e Make `� � � Year
Model: C -,a j c.en ce r License No. S'/v97 4F`iZ R
12. Describe what you did after the accident occurred:
i�'e.0�ctti t"73slcr C2 i1 c( �Cf/>7 nL�Pt� LJec f)c�'rte
13. Describe the conversations you had, if any, with County personnel during or after the
incident occurred:
i;M n -701n dei l��`c,Grs/� +�r yvt,( f) -,g C✓%ia
2 of 3
Kittitas County Claim for Damages Form
Revised 9/2012
Filed for Record 11/15/2017 03:47:58 PM - Kittitas County, WA Auditor -201711150066 Page 3 of 8
14. Describe the damages or injuries which you sustained as a result of the
9 incident:
Alava_ -7t. ✓yw �o%1' 1l✓1,n Ah, i, o -717) -/%-a
-a_ Pa/' i J2C --4 min /v / WA /- /J-%
nl'r(im-ir <)de r -ea r Gr >7a n e A4 y, -% a a
15. What is the amount of damages claimed? (Include estimates and bills, if available):
x.6.0
16. How did you identify the County as the parry responsible for your damage?
% A&-5 n a b;-4'(' d /J -y
(2
17. List the names and addresses of all witnesses to the incident:
18. Are you covered by insurance? ,, If yes, who is your insurance agent/carrier?
3 0 0 IZAA
Dated this I H +:� Day of Nuv-e-� Fj�e-r' -,201-7.
Signature of Claimant
Subscribed and sworn,(, Mpd) to before me this day of /V ftm h.l,r' , 201-7.
GOA D'q
Seal O ` Q
,
d
Notary Public in and for the State of Washington
JSt ICS ,®° Residing at G
I.
\'� c° ry201 00 �C)VA S
�j�/�h°ae aoeo°°° � ♦1\` L,]LI.JL�Q.� I / K - /J�\moi
111111100
3 of 3
Kittitas County Claim for Damages Form
Revised 9/2012
`Filed for Record 11/15/2017 03:47:58 PM - Kittitas County, WA Auditor -201711150066 Page 4 of 8
INVOICE #22 11/14/2017 2:21:26 PM RO# 1362 PROSTAR COLLISION
Page 1
PROSTAR COLLISION
303 N Wenas St
Ellensburg, WA 98926
509) 925-2233, 609) 925-2238 Fax
Delivered Date: 11/16/2017
INVOICE
RO# 1362
Est: Justin Henderson
Jackie Peebles 10 Dodge Challenger
Co
732 Stingley Color:
KCSD
Rd
i
Ellensburg, WA 98926. Type; PC 2D Cpe
Home: VIN: 2B3CJ7DWXAH142503
Adjustor:
Phone:
509-899-2246
Work:
I Prod Date: Plate:
Claim #:
Deductible: 0
Cell;
Odometer:
Loss
i Type:
Underline indicates Su lenient Line ....... ........ ..................
= Who Pays?
.........
{I = Insurance, C = Customer]
Qty Type
Description
R
_P
Parti# Amount
__...
SUP
# Labor
_ .._;.�. ............._ _..I____._.
Op ; 1
_
Labor Paint s
n
[ its
_ nits_'_
...... _....._...
L Door Opening Panel Complete
L Rocker Cladding
# i
I
: Blnd
1.41 C
Parts
I
Body
i
R&I
0.4 ! i C
I
Existing
L Cowl/Dash Extension
J i
; Body
! R&I
0.2 C
Parts
j Existing
; L Cowl/Dash Trim Panel
i
;
i
Body
R&I
0,31 C
Parts
Existing
L Rocker Scuff Plate
Body
; R&I
s C
i1 Parts
I Existing
L Door Opening Weatherstrip
;
Body
R&I
0.4 ! C
j Parts
L Frt Door Assembly
Body
R&I j
0.8 C C
I ' Existing
L Roof Adhesive Moulding
g
Body
R&I
0.4 ( i C
Parts
Existing
L Quarter Outer Panel
1
i
Body
Rpr
I
2:0 i C I
L Quarter Panel Outside
Refn
2.41 C
Parts
Existing
` L Quarter Splash Shield
I
Body
Y
R&I
i
C
E Parts
Existing
L Quarter Fuel Door
j
(
I Body
j R&i !
0.5 ':. j C
L Quarter Side Trim
{ L Quarter Trim PanelBody
I
Body
I R&I
R&IPanel
I C
1
I
Rear Seat Assy
i L Quarter Glass
1
Body I
Glass
R&I I
R&I
0.5 . C
Luggage Lid Spoiler
I
I
Body
R&I
0.4 ! C
L Rear Combination Lamp i
;
Body
!
R&I
C
Rear Bumper Cover
I L Rear Bumper Mudguard i
?Body
Body
R&I i
R&1 1
2.4 ' C .
0.21 C
De -Nib And Finesse
{
Addl ;
0.5 G C
i Parts
;Clear Coat i
3
Addl 1
1.41 C
Existing
Post Repair Scan i
Mech
Addl
0.6 ? I C
1 Parts New
1 ;Parts New
Protect Interior From Repair Debis +
:Clean & Retape S 1.27 Per FtI
New I 5.00
New 13.43
Body
Body
Repl .
0.5 ! C 3
Bards -New
I Ap • Bed
Repl
0.4 C
Parts
;
Repi0.3
C
i Existing
Tint Color
j
Addl I
1.0 C
Part""
Spray But Gacds �e E St e� 9 Ma4sh
;Repi;
0.5 C!
I Par#S New
Restore- xrosi<sr+ Protestit37.- —$ 2,8
Repl j
0.3 C
I Existing
I Mask Interior Jams 1 Thresholds
!
Addl
0.4 C
i
I Existing
Mask For Primer Surfacer
I
Addl
3 0.4 j C
Parts
Existing
Feather Prime & Block i'
t
Addl ,
0.5 C
1 ! Parts AM
1Pnt/Mat
I Urethane Replacement Kit !
Paint/Materials
44,05
Body I
Repl
C
1 Haz
} Hazardous Waste Disposal I
309.601
15.00 I
l
Addl 1
Addl
C
F C I
I
INVOICE #22 11/14/2017 2:21:26 PM RO# 1362 PROSTAR COLLISION
Page 1
Filed for Record 11/15/3O17O%:47:58PM KiftbooCounty, VVAAuditor 301711150088 Page 5of8
Delivered Date: 11/16/2017
Labor1,229.00
9.4
Parts
545,20
Additional Costs
3U60
545.20
Glass
Taxes
13152
Grand Total
f 1,748;60
Body
9.4
58.00
545,20
9.41
5&00
545.20
Glass
1.81
6000
10800
11.81
60.001
108.00
Mech
0.61
80,00
48'00
0.61
80.00 i
48.00
Paint
m
58.00
527.80
9.1 1
58.001
527.80
Haz
15,00
15,00,
309.60
Parts AM
44;05
44.05
Parts Now
18.43
SubTotal
20-9
1
1,616 08
20.91
Taxes
132.52
Grand Total
1.748-601
1
1,748.60
Due from Insurance
ue frOM'Customer
1,61608,
Tax
0.00
Tax
132.521
Tota I
0.00
Total
1,748.60
Total Amount
1,748.604
INVOICE #22 11/14/2072:21:26pw no#1uee pnoeTAmCouuaIOm
M
Filed for Record 11/15/2017 03:47:58 PM - Kittitas County, WA Auditor -201711150066 Page 6 of 8
Kittitas County Sheriffs. Office
Detail Incident Report -
Incident Number: S17-11465
Incident: CAD INFORMATIONAL REPORT
Observed: Information ONLY No action
When Reported: 09:41:34 10/19/17
Reference Number:
Area: AREA 11, CITY OF
ELLENSBURG
Location: 307 W UMPTANUM RD;
KITTITAS COUNTY SHERIFFS
OFC
Occurred Between: 09:41:31 10/19/17
And: 09:41:31 10/19/17
PARTICIPANTS:
Name: PEEBLES, JACQUELINE M.
DOB: 07/29/1968 - Race/Sex: W/F
Address: 732 STINGLEY RD
ELLENSBURG, WA 98926
Home Phone: (509)899-2246 Work Phone: (509)899-3344
VEHICLE INFORMATION:
1) Status: INVOLVED
VIN: 2B3 CJ7DWXAH 142503.
Make: DODG
Color: /
Description:
Reg. Owner: PEEBLES, JACQUELINE M.
rplwdir.0
License: DODGE
State: WA
Expires: **/**/**
Year: 2010
Model: CHL
Type:
Doors: 0
Value: $
11/14/17
Filed for Record 11/15/2017 03:47:58 PM - Kittitas County, WA Auditor -201711150066 Page 7 of 8
It
Detail Incident Report
NARRATIVE:
Name: FOSTER, NATE
Kittitas County Sheriffs Office Uniform Incident Report
CASE #: S 17-11465
CRIME: Info
SUSPECT: N/A
NARRATIVE:
On 10/19/2017 while on patrol for the Kittitas County Sheriffs Office I was
parked in the rear lot of the Sheriffs Office next to a vehicle WA License
SNSTER8. I was moving items from my front passenger seat to my rear passenger
side seat so I could conduct a vehicle transport. When I opened my rear
passenger side door, the door swung wide and struck the vehicle next to me.
I observed that when my door struck the other vehicle it caused a small dent.
I then contacted the owner of the vehicle a Jackie Peebles and advised her of
what had happened. At this time I am filing this case as informational only.
[] NON -DISCLOSURE NAME(S):
Distribution:
[ ] Upper District Court
[ ] Lower District Court
[ ] Detectives
[ ] Prosecutor
[X] Case file
[ ] Other:
I declare under penalty of perjury, under the laws of the State of
Washington, that the foregoing is true and correct to the best of my
knowledge.
Signed at Ellensburg, Washington this 19th day of October 2017.
Deputy Name: Nate C. Foster
Badge number: 33
Page 2 of 3
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Filed for Record 11/15/2017 03:47:58 PM - Kittitas County, WA Auditor -201711150066 Page 8 of 8
Detail Incident Report
Approval: -
Distribution:
City Attorney: f
City Prosecutor: I J
Child Protective Services: [ ] Courts: [ ]
Detectives: [ ]
Juvenile Probation: [ ]
Juvenile Prosecutor: [ ]
Mental Health: [ ]
Misdemeanant Probation: [ ]
Prosecutor: [ ]
7 Day Board: [ ]
Student Affairs: [ ]
WSP: [ ] Other:
_
Page 3 of 3
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