Hjertstedt ` � RECEIV��
FEB 21 2014
NOTICE OF CLAIM FORM to the Gity of Saint Paul, MinnesoQl�( CL�;��
Minnesotn Srate Srcttute 466.05 states thnt ".,.ei�eryperson...who claims damages from any municipality...sha11 cause to be preserited to the
goverrzing body of the mt�nrcipality withitt 180 days after the alleged(oss or rnjury is discovered n��otice stating the tirne,pfuce,and
circumsrances thereof,and tke amourtt r+f compensation or other relief 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 wil(receive a
written acknowledgement 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 �'e-a--� - Middle Initial�,.Last Name,�i�''�'.S't''�d-'�_� Q�l-� Mu.rt a. Qr
_ .9
Company or Business Name �► ��t� �ar�. f�� S a C,t,a`� t� can lnp 1•�a 1-F 07 'r'�s��n�-
Are You an Insurance Company? Yes No If Yes,Claim Number?
Street Address ���� -�4 C+��,,,�j;,,,�.-: Q DAe�
City �• Po�.+.► � State M IJ Zip Code � S/0 5
Daytime Phone(�v5) )�-2�05 Cell Phone(- ) - Evening Telephone(_) -
Date of Accidend Injury or Date Discovered l 2LZ�'f2A I�j Time < < am/(�'
�\�Ww�
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.. _ _
P L�daS'�. 5C C^ A T'TAGt-!�D �X.PLAt�.f A Tt D N �'(�+�1 O�r�lG�tz..
.J� ��,►...���, �� �� s-� PA��, po�..►cE p� .�r-.�'-rt��,.s,�r,,
Please check the box(es)that most closely represent the reason for completing this form:
❑My vehicie 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
[�"1�y vehicle vwas wrongfully tov�ed and/or ticketed ❑I w�s.lnjw�ed on City property
L'1'�Chher type of property damage—please specify,�tZDIJT�r'X-�DR- atJC? ..1�►�5 v� v,n i '�" 1 � 3 S F��°`�
❑ Other type of injury—please specify �' �' d
In order to process yourclaim you need to inelude eopies of all applicable documents.
For the claims types listed below,please be sure to inctude 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 elaims: legible copies of any ticket issued and a copy of the impound lot receipt
�Other property damage claims: two repair est� ates if the damage exceeds$500.00;or the actual bills
and/or receipts for the repairs;detailed list of dam�aged items
O Injury ctaims: medical bills,receipts
� 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
Failure to complete and return both pages will resalt in detay in the handling of your claim.
Ail Claims- ���com ete tl��ec�i4n ,
Were there witnesses to[he incident? Yes I!ro U�tknt�wtt {�ir�te)
�'rcivide,their narn�s,add .:�... and telephane numbers: l��R-Y ..)A^� '�''F�fl'ct�.'��tJ._
�,�,12��, '2�►9,.����k'�« _
Were the,golice or law enforcement called? Y�s No Unlrnown (cirele
If yes,,what degartment or agency? , �'Q L,,,�,5� , ,Case#or report# (J�- �'��'�fi? '
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 aspg�sibie. If necessar ,attach a diagram, ,.
�5 �� t' J M 5 ,S _ _
Please indicate the amount you are seeking in compensation or w at you w uld like the City to do to resolve this claim
to your s isfacrion. CJeL ' � `,.,.� `
�-o .� 2 � l � y � Z. __
Vehicle Claims- lease com lete this section ❑ check box if this section does not a 1
Your Vehicle: Year Make Madei
__ _
License Plate Number State Color
Regi stered Owner
Driver of Vehicle
Area Dama ed
City Vehicle: Year../��- Make I+►+�t�del
License Plate Number - - _�W State - Color
Driver of Vehicle(City Employee's Name) __
Area Daznaged_ __ _
In'nr _Claicns- lease com lete this section ❑check box if this section does not a 1
Hnw were you iniured� � �
What part(s)of your body were injured?
.
Have you sought medical treafinent? Yes No Planning to Seek Treatment(circIe)
When did you receive treatment? �� (provide date(s))
Name of Medical Provider(s):
Address _ Telephone
Did you miss work as a result of your'njury? Yes No
When did you nuss work? 6 _ {prow��l�date(s))
Name of your Employer:
Ad�tess _ Teteph�c�e _
�Check here if you are attaching more pages to this claim form. Number af additional pages s .
By signing this form,you are stating that all information you have provided is true and correct to the best
of your knowledge. Unsigned for►ns will nat be processed.
Submitting a:false claim can result in prosecution. Date form was completed a ' a�d�� y
Print the Name of the:Person who Campleted this Form: �J�-C�rt In(1- ���r� f G�f
_ � .
Sfgnature af Person 1Vlalzing the Ciaim: • :
�' �� • .
Revised Fe6ruary 201 I
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Pride, Professionalism,&r Partnership
JENNIFER MINK �J�T�IrC. C�tL���---
Police O,�cer
POLICE DEPARTMENT
CTI'Y OF SAINT PAUL
367 Gr'ove Street �oice Muit:651-1b6-90D0 txt 71776 '
st+rrtTl�ittJ.MN-SS1Qt jrr.a,hrk@ci.st�+rrl.mrl.irs�
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If you havc questions regazding yout rcport,caD:
Safnt Paul Police Records Unit (651)266-5700
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��lZ�1111 $S,���.
G SBRVIG
1135 Edgcumbe January 8, 2014
St. Paul, MN
JOB PROPOSAL
Front Entry Door Replacement
Rarkway Building Services will provide the labor and materials to replace the front entry door at
1135 Edgcumbe in St. Paul per the following specifications:
• Remove and dispose of existing door.
• Install new 6-panel steel entry door with 20" full glass sidelight.
� Reinstall existing lock set and handle.
• Install insulation.
• Reinstall existing storm door.
• Reinstall existing interior casing.
• New door will be primed.
• Painting is not included in this proposal.
■ Total price to replace front door: $1695.00 (includes tax)
Greg Lundquist
Parkway Building Services
License BC645220
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TW � N p 0 W Estimate
REPLACEMENT
C O M PANY Lic. # BC117686
5153 Clear Spring Dr.
Minnetonka, MN 55345
N�rr�efAd�ir�ss .
,.-� .��.�, .:�.. , �.
- _..
First Service Residential Ship To
1801 American Boulevard East, Suite 21 1135 Edgcumbe Rd
Bloomington, MN 55425 St Paul, MN 55105
Date Estimate No: `Pro�ect
01/06/14 6999 1135 Edgcumb...
_
' I)escnptroti Quantity �ost Tota[_, ,
Steel 6-panel Entry Door w/20" full glass sidelight 1 2,323.00 2,323.00
Includes: 0:00
Removal &disposal of existing door
Installing &insulating new door
Re-installing existing interior casing
Re-Installing existing handle/lock set
Re-installing existing storm door
Permit fees to be determined
Painting/Staining not included
Please Gall Reter Hill with any questions C� 612-805-4730. Thank you! -�-a#�� '��� '���,���p(�
'windowreplacementco.com 952-93�4-0005 info@windowreplacementco.com
_ , ,,r._.�^..~, Contract �nvoice
� r ' � � 2�1�
,��+� Invaice#: 14532
� Date: 12/31l2013
r � ,
•
Billed To: 1135 Edgecumbe Rd Project: 1135 Edgecumbe Rd
c!o �irst Service Residentiai 1135 Edgecumbe Rd
1801 Ame�ican Blvd E#29 St Paul MN 551Q5
Bloomingfon MN 55425
Due Date: 01/30/2014 Tertns: Oue on Receipt Order#
Qescription Taxable Amount
Emergency Board-Up Y 380.88
S�{es Tax 29,04
Notes:
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�A��urov�� by: _��_�_�______.--------..,_--.�_—!
A servfce charge c@F00% per annum will be charged on aI!amount�s
overdue on regutar s#aterrient rlafes.
P/ease make ch�cks payable to: C.lean Response, Inc. Amaunt Due �4Q3,g�
48�Ptior Ave. North
S#.Paul, MN 5�104
651-646-3408 phone
fi51-817-2506 fa�c
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tf
Restoration Contract�rs,inc. dba Clean Response
480 N.Prior Ave.
b�1-646.-�..4.0� 5T.Paul.MN.SS104 '
Phone:65I-G46-3408
Fax: 65i-9I7-2506
Prc�perty: 113�Edaecumbe I�d Home: (651}b90-2$?� :
St.Paul ,MN 55105
Operatar Tnfo:
Operator: CHRIS
Estimator: Chris Simon Business: (b5})646-3408
Position: Bstimator
Company: Clean Response
Business: 48�N.Prior Ave.
St.paul,MN 55104
Type of Esrimate: a'>1(3NE>
Date Entered: 116/2014 Date Assigned: 1�2812013
FriceList: MN�vIN7X NOV13
Labor Etf'iciency: Restoration/Service/Remodel
Estimate: 1135EDGECUMBERD '
. Restora�ion Contractors,Inc. dba Ciean Respr�nse
480 N.Prior Ave.
�tl�1-.646-3408 ST.Paul,MN.551.{)4
Phone;651-b46-34��
Fax:651-917-25�G '
1135EDG�CU�iSERI3
iI35EDGECUMBERD
I?ESCRIPTIUN t2NTY REMOVE REPLACE TOTAL
1: �n�ergency service call-a€ter.business 1.t10 EA fl.00 19036 I9Q.3b
hrnars
Total: 1 I35BI3GECUIvIBBRD 190 3�
Labor
IIESCRIPTION QNTY REMOVE REPLACE TaTAL
2. Temporary Repairs-per hour-after 2A0 HR 0.00 95.2b 1943.52
haurs
Rep�ired.kicked i.a doox an 12-?S-I3 for 2 hours
Totals: Labar �g�.�?
I.ssine Item Tca�ls:I135EDGEGUi�IBERD 381},S8
1135�DGBCUMBERD 116/201.4 Page:2,
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,
, � •
�estoratio�Cantractors,Inc. r�ba Cieari Itespanse
" 48Q N.Pri�r Ave.
Q�51-64�-3.4.08 S'T.Paul,MN.551d4
Phane:651-64G-3408
Fax:651-917-?505
�ummary
Line Item Total 380.88 '
Cleaning Sa1es Tax C 7.625% 29.Q4 ,
Replacement Cost Value ��09.92
Net Claim $409.�2
Chris Simc�n
Estimator
II35�:DGECLTMB�RL3 U6/201.� Page:3