Butchko NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
Minnesota State Statute 466.05 states that " ...every person...who claims danzages firom any municipality...shall cause to be presented to the
governing body of the municipality within 180 days after the alleged loss or injury is discovered a notice stating the time,place, and
circumstances thereof, and the amount of compensation or other�•elief demanded."
Please complete this form in its entirety by clearly typing or printing your answer to each question. If more space is
needed,attach additional sheets. Please note that you will not be contacted by telephone to clarify answers,so provide as
much information as necessary to explain your claim,and the amount of compensation being requested. You will receive a
written acl:nowledgement once your form is received. The process can take up to ten weeks or longer depending on the
nature of your claim. This form must be signed,and both pages completed. If something does not apply,write`N/A'.
SEND COMPLETED FORM AND OTHER DOCUMENTS TO: CITY CLERK,
15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102
First Name �, j C��Gf C l Middle Initial � Last Name ��.� �G� �G� L?C�����D
—�--r�——
Company or Business Name ��3
Are You an Insurance Company? Yes/�If Yes, Claim Number? �
Street Address �/,��I ,� [�c�r11 C tf�
City �1 t - ,�G�i..t.,� State fZ�.11.7 Zip Code ��5��� �
Daytime Phone(�)�-�Cell Phone U - Evening Telephone(_) -
Date of Accident/Injury or Date Discovered �•-� 3 �l 3 Time x:-� am/�
Please state, in detail,what occurred(happened),and why you are submitting a claim. Please indicate why or how you
feel the City of Saint Paul or its employees are involved and/or responsible for your damages. 1;'1/GZ.fPJL t����-S
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Please check the box(es)that most closely represent the reason for completing this form:
❑ My vehicle was damaged in an accident ❑ My vehicle was damaged during a tow
❑ My vehicle was damaged by a pothole or condition of the street ❑ My vehicle was damaged by a plow
❑ My vehicle was wrongfully towed and/or ticketed ❑ I was injured on City property
�Other type of property damage–please specify
❑ Other type of injury–please specify
In order to process your claim you need to include copies of all applicable documents.
For the claims types listed below,please be sure to include the documents indicated or it will delay the handling of
your claim. Documents WILL NOT be returned and become the property of the City. You are encouraged to keep a
copy for yourself before submitting your claim form.
O Property damage claims to a vehicle:two estimates for the repairs to your vehicle if the damage exceeds
$500.00; or the actual bills and/or receipts for the repairs
O Towing claims: legible copies of any ticket issued and a copy of the impound lot receipt
�Other property damage claims: two repair estimates if the damage exceeds$500.00;or the actual bills
and/or receipts for the repairs;detailed list of damaged items
O Injury claims: medica]bills,receipts
O Photographs are always welcome to document and support your claim but will not be returned.
Page 1 of 2—Please complete and return both pages of Claim Form
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Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims—please complete this section
Were there wifiesses to the incident? Yes �'�a Unknown (circle)
Provide their names, addresses and telephone numbers:
Were the police or law enforcement called? Yes � �Io Unknown (circle)
If yes,what department or agency? � Case#or report#
Where did the accident or injury take place? Provide street address,cross street, intersection,name of park or facility,
closest landmark, etc. Please be as detailed as possible. If necessary, attach a diaa am.
Please indicate the amount you are seeking in compensation or what you would like the City to do to resolve this claim
to your satisfaction. � �7 4'��C� � �
Vehicle Claims— lease com lete this se^tion ❑ check box if this section does not a 1
Your Vehicle: Year Make Model
License Plate Number State Color
Registered Owner
Driver of Vehicle
Area Damaged
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name) �
Area Damaged
In�ur�Claims please com�lete this section ❑ check box if this section does not applv
How were you injured?
What part(s)of your body were injured?
Have you sought medical treatment? Yes No Planning to Seek Treatment(cir(p�ovide date(s))
When did you receive treatment?
Name of Medical Provider(s): Telephone
Address
Did you miss work as a result of your injury? ' Yes No
(provide date(s))
When did you miss work?
Name of your Employer: Telephone
Address
�Check here if you are attaching more pages to this claim form. Number of additional pages�.
By signing this form,you are stating that all information you have provided is true and correct to the best
of your knowledge. Unsigned forms will not be processed.
Submitting a false claim can result in prosecution. Date form was completed /a ��-�3
Print the Name of the Person who Completed this Form: �) C`2G � ! _,l��c.L��C�� '� C7 _
Signature of Person Making the Claim:
Revised February 201]
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:ALL# - SERVICEMAN: INV# -� -
A DRAIN CLEANER
P.O. Box 28812
Oakdale, MN 55128
651-430-0880
;,,, 651-578-3050
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SERVICES JOB COMMENTS COST
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PREVENTIVE MAINTENANCE: � (10%) � SR � 2nd LINE DISCOUNT(50%) DISCOUNT
� 3 mo. �6 mo. � 18 mo. -- - TOTAL-LABOR
GUARANTEE: � 30 days �60 days(ROOTS ONLY) � NONE TOTAL-PARTS
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COMMERCIAL ACCOUNTS NET 30 DAYS __ - AMOUNT DUE ,-':,�:� ;:�'
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�LEASE READ BEFORE SIGNING: "ALL WORK PERFORMED WITH STANDARD EQUIPMENT"COMMERCIALACCOUNTS NET 30 DAYS OR A$5.00 PER
JIONTH WILL BE ASSESSED AND ANY GUARANTEE WILL BE NULL AND VCID"CHECKS-$15.00 CHARGE ADDED TO ALL DISHONORED CHECKS,AND
aLL LEGAL FEES INCURRED FOR COLLECTION OF SAID FUNDS."OUR COMPANY IS NOT RESPONSIBLE FOR THE DISCOVERY OF AND/OR CONDITION
�F DETERIORATED LEADING,SETTLED,BROKEN,OR DAMAGED PIPES.ANY REPAIR TO SAID PIPES ARE AT THE EXPENSE OF THE OWNER."OUR
:OMPANY IS NOT RESPONSIBLE FOR ANY BACK-UP PREVIOUS TO OR DURING GUARANTEE PERIOD.'*CUSTOMER IS AWARE THATTHE SERVICEMAN
�ERFORMING DRAIN CLEANING DUTIES IS NOT A PLUMBER AND CAN NOT PERFORM ANY PLUMBING D.UTIES AS STATED BY LAW. " PARTS ARE
=XTRA. .
:USTOMER:SIGNATURE SERVICEMAN SI.6NATURE:-`��
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AVICEMAN:
DRAIN WATCH, lNC,
P.O. Box 28812
Oakdale, MN 55128
952-929-7914
651-439-4887
DATE: � /. �
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SERVICE AT:
COST
JOB COMMENTS
SERVICES �
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GUARANTEE: 30 days � �, "�!�
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,�• ,� ,,r,�,; -;�pLU�/15ER AiD CAN lvOT•°�RF�°�ANY°LUUISING DUTlES AS STATF�BY LAW.
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i SERViCEMAN Si . � R�
CUSTOMER SIGNATURE i '.
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BUTCHKO DECORATING
1138 Burns Ave.
St. Pau1,. MN, 55106
Phone 774-7869
PRCPOSAL
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Dear Sir;
The undersigned proposes to furnish all materials and perform all labor
necessary to complete the following:
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All of the above wo to be completed in a substantial and workmanlike
manner for the sum of ���,, ��;°
Payment is to be made upon completion of job.
11ny alteration or deviation from the above specifications involving
extra cost of material or labor will only be executed upon written orders
for same, and will become an extra charge over the sum mentioned in this
contr.acY. All agreements must be made in writing.
Contractor: Butchko Decorating
BY: �"���r�
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ACCEPTANCE
You are hereby authorized to furnish all labor required to complete
Lt�e work mentioned in the above proposal� for which the undersigned agrees to
nay the amount mentioned in said proposal, and according to the terms thereof.
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PROPOSAL
651-774-0330 Faz 651-771-8983
E-mail cuicurella(�a,me.com
Date: August 15,2013
Job Name: Sewer Repair
Job Location: 1299 Reaney Ave.
Phone: 651-774-7869
COMMERCIAL UTILITIES,INC.
1146 EAST SEVENTH STREET
ST.PAUL,MN 55106
TO: Mike Butchko
1138 Burns Ave. --
S�Paul,MN 55106
We propose to furnish all labor,eqnipment,material,and permit to repair sanitary sewer service from house to
sewer main in street with 4"PVC pipe complete in accordance with these specifications for the sum of FIVE
THOUSAND NIlVE HUNDRED AND NO/CENTS($5,900.00).
Price does not include: Any sod restoration.
Price includes: Restoration of street and re-cementing concrete floor in the area of the new sewer line.
T`he following items are not included: SAC,WAC and or other connecrion charges,dewatering,soil correction and or
replacement,removal or buried obstructions,jacking,frost charges,rock excavation,replacement of old lead water
lines,underground irrigation lines,yard lights,compaction tests,hazazdous material handling,existing service cut offs,
design and plan fees.
JOB PAYABLE:upon completion.
All material is guaranteed to be as specified. Ali work to be completed in a worlrnian liice 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 Workmen's Compensation Insurance.
U
' �G�� DATE_ 8/15/2013
AUTHORIZED SIGNATURE -
Note: this proposal may be withdrawn by us if not accepted within 30 days.
ACCCEPTANCE OF PROPOSAL—The prices,spec�cations and conditions are satisfactory
and are hereby accepted. You are authorized to do the work as specified. Payment will be
made as outline above. DATE
5IGNATURE
a) Any person or company supplying,labor,or material for this improvement to your
property may file a lien against your property if that person or company is not paid
for the contributions.
b) Under Minnesota law,you have the right to pay persons who supplied labor,or
materials for this improvement directly and deduct this amount from our contract
price,or withhold the ambants due them from us unti1120 days after completion ar
the improvement nnless we give you a lien waiver signed by person who supplied
any labor or material for the improvement and who gave you timely notice.
---- ----------- -- — --- ';
City of Saint Paul Sewer Asses�ment Program _
for Repair of Private Sanitaty Sewer Services
Applicaf�on far Se��er Assessm��t
As owner of the property Iisted below,I have reviewed the Sewer Assessment Pro�am instruetians and aaree to �
the following terms a.nd conditions:
Administration Fee: I will be charged a one-time fee of$60.00 for administration,which will be included in
the cost assessed against m;�property,
Payback period: Sewer repair costs, administrative fees, and interest will be collected through my real
estate taxes over a iwenty year period. Interest charges wili be based on the f�ced rate
approved by the Saint Paul City Councii and is subject to change wittiout notice. The
current rate is 4.5Q%. I may pay tbe unpaid balance in full at any time during this
twenty year periad,withaut penalty.
Waiver of Appeai: I AGREE TO WANE MY RIGHT TO APPEAL THIS ELSSESSN�EElVT. I
AGREE TO PAY THE COloiTRACTC3R PROMPTLY UPON RECEIPT OF T�
JOIl!'T CHECK ISSUED BY TH� CIT'YY. T�E CITY IS NOT RESPONSIBLE
I+'OR AN�' CHARGES THE CONT�2ACTOR MAY LEVY FOR �AII�URE TO
PAY PRON�PTLY.
I?amage Ar�rards: If the repair to my sewer se;vice is necessitated by damage resulting from the actions of
another pariy, and I collect compensa�ion froir_ that party, I a�ee to apply the futi
a.mount collected towards the unpaic�5aiance oi±�e assessu�e:�..
Properry Address_ t �G / ��� '� -
location of sewer repai�'f
Owner's Name(print): C� /��/CT7-�� rF'�',.G�G�7�'�
Owner's Si�natl!re: ,(� /�,���""' .���
� ` y � � (� ��� ���` � �
Owner's Address: / ��(! ��� �.�� V`--�"` <'
� � (if di�erent u orn property address)
TeIephone Nlimber: ?7 � — �� � l
Date: V � � L l �
Please return this completed"A�plication ior Sewer a.ssessr�en�"fo*-n; �:�c 2:least t�ree cont�2e*_o:bid��o:
St.Paul Sewer Utility ��� ��� ��'�^'`'"`'���av a�s�be 1,"^_`�iOQ 0'.°.:�aiied.
Attn: Lori Lemlce Pax ni.�:be:: 6�'�9�-�5�:
700 City Hali Annex � '�.�J'�� Em2i1 zddress: ior.lertitievci.�naui.Ts�.u�
25 W.4th St.
St.Pau1,MN 55142 ,�' � G�`�(j
If you are deliaquent on your properiy tazes,yot�.are not eii�ble to use the program. Please catl Lori at
(6�1}266-6230 if you have questions.