The URL can be used to link to this page

Logsdon, Mary Lou ��ivED JUN 16 201�t NOTICE OF CLAIM FORM to the City of Saint Paul, M�}��K Minnesota State Statute 466.05 states that "...every person...who claims damages from any municipality...shall cause to 6e 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 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 e�lain your claim,and the amount of compensation being requested. You will 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 dces 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 `—� v Middle Initial� Last Name ��Ps'�v� Company or Business Name '— l 4=�C// Are You an Insurance Company? Y s o If Yes,Claim Number? Street Address � �'�-�-J L� City �// � /a-iJ�L, /!�!/IG State /� Zip Code �^�d � Daytime Phone��Cell Phone�)��vening Telephone( S — 4�� Date of Accident/Injury or Date Discovered�" �� i� - � am/ m Please state, in detail, what occurred(happened), and why you are submitting a claim. Please indicate w y or hp�v you feel the Ci of S int Paul or its employees are involved an or res on 'ble for y ur dama s. �� `� -� ,�S �s _ �:�� SstJ� � ,� ,� � s l � s 4 �� 5�-- �c � °� �'�'��-�r.d� o 0 o Y_-�ri1,� r Please check the box(es)that most closely represent the reason for co pleting 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 ❑ y vehicle was wrongfully towed and/or ticketed _ ❑ I was injured on Cit property Other type of property damage—please specify G��i� ��/� -- ------ • C3�Piner Type ofinjury=p�Iease speciry � /�� _ 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 WII.L 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 O 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: medical 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 Failure to complete and return both pages will result in delay in the handling of your claim. All Claims-ulease comulete this section Were there witnesses to the incident? Yes Nr,�Unknow (circle�d Provide their mes, address s and tele h ers: �C�j �i-- � � �, ��/ Were the police or law enforcement called? Yes N Unknown (circle) If yes, what department or agency? Case#or report# Where did the accident or injury take place? Provide street addr s��.s�t, ' r ion,name of park or facility, closest landm ,etc. Please be as etailed as ossible. If ne es , ttach ia �� ili,C� �Q �-- i.c.� � r �� r.�� Please indicate the amou e see ' g in compensation o hat u would like the C' to do to resolve this cl ' to your satisfaction. G O T�J-/� � �� - rz-:�—� _ Vehicle Claims- lease com lete this section check box if this section d t 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- lease com lete this section check box if this section does not a 1 How were you injured? What part(s)of your body were injured? Have you sought medical treatment? Yes No Planning to Seek Treatment(circle) When did you receive treatment? (provide date(s)) Name of Medical Provider(s): Address Telephone Did you miss work as a result of your injury? Yes No When did you miss work? (provide date(s)) Name of you `Employer: Addr s Telephone J Check here if you are attaching more pages to this claim form. Number of additional pages� By signing this fornz,you are stating that all informalion 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 `� � l Print the Name of the Person who Completed rm: � � �11�� Signature of Person Making the Claim: � Revised February 2011 1 GENADEK °` LANDSCAPING AND EXCAVATING INC. Phone#612-369-4698 Fax# 651-552-2066 RETAINING WALLS DEMOLITION EXCAVATION Incorporating courtesy, dependability and integrity into everything we do. 6-11-2014 Work to be performed: Grading and Retaining walls Project description: Segmental retaining wall reconstruction, 567 Bidwell Street Walls: Repair wall as follows:remove,stack and pallerize blocks for re-use. Take wall down to base and oversize in a V-pattern. Compact subgrade and install new base material—minimum depth 6". Install new drainage aggregate. Install new corner units and 4"cap stones as necessary where the block can not be re- used. Provide and install new double shredded hardwood mulch and plantings in the 2 tiered sections. Remove fill soil in tl�e re-inforcement zone of the retaining wall and stockpile off-site until reconstruction begins. Total square footage for repair not to exceed 260 square feet. $8,750 Proposal includes: *Re-use existing block,supply new as needed,cap,installation per engineering standards and clean-up *Excavation and grading work. *Placement and compaction of structural soil. *Finish landscape plantings,sod,seed, Proposal does not include: *Handling of Hazardous Materials,permit fees,surveying,dewatering,soil correction. *sprinkler repair, , *NO warranty implied or given on retaining wall work. *sewer,water or utility removal or hand excavation around utilities. *Driveway,street,parking lot or sidewalk repair reptacement. Notice of Pre-Lien This notice is to advise you of your rights under the Minnesota Law in connection with the improvement to your property. Any person or company supplying labor or materials for this improvement may file a lien against your property if that person or company has not been paid for the contributions. Under Minnesota Law,you have the right to pay persons who supplied labor or materials for this improvement directiy and deduct this amount from our contract price or withhold the amounts due them from us until 120 days after complerion of the improvement unless we give you a lien waiver signed by persons who supplieA any labor or materials for the improvement and who gave you a rimely notice. No other contracts or conditions,no warranty or guarantee implied or given. If you have any questions please call Stan at 612-369-4698. Genadek Landscaping and Excavating Inc. 716 Third Ave., Mendota Heights,MN 55118 Authorized by: a„"'��; � ��aF�� . �. , � ,� ",��'"� - r� �� b +��-,�� ' �, ,. � ��. �, ,m. `� � . •�� ,� ,�.� �r ... K� h� ��`.# ��``�P »'� ",�,,� 1ly� �� ; ~3', �Jy, t �f ��^ � t�#x*. . 'f'4' �.. � // / � ,/ ';�!'� �� V I L ! ' 1��'.�� f Sl-, � � � �� ; � , .�_�� +� ;a � � ''ti., `' � � _..,_.,, •• .�.r� � �' � /( / :t ��_ � �� / �' � ��: � �,a�� ,. ��.. ._r � _� �.� ,: �, �� t _� �I�7 �'-o-��, �+ .� ,� t�� _„"�" �. + A. � „J+ V.' � . .. �'�:',�.: . � ae �� '- +.. _ _�� .. � ... - �-�'un .-. . . .�. .,. �> ' Y�,��ti..', �,� ' � F4.: .K�r '�.y,.�„ +k :•�` �a�'M�ic � *�;: �w�s. �-�. � �.� �- t,we-.; ��c � \<�c�,'$ L �� k ��. ' � � °� .� � „s ` . .._,. : ...., . .. Y,....?. ,, ' � �� /� ,�� S� � � , ��=� ��