Borene, Lisa RECEI�IED
JUN 18 2014
NOTICE OF CLAIM FORM to the City of Saint Paul, Minr{���t� C L E R K
Minnesota State Statute 466.05 states that"...every person...who claims damages from any municipaliry...shall cause to be presented to the
governing body of the municipaliry 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 eacplain 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 ����— Middle Initial �� Last Name ������l�
Company or Business Name �u-�G� �h ��`'�� �'`�2� ����� � �h�t � � �
���1 'YYi,f�� l �
Are You an Insurance Company? Yes�,�f Yes,Claim Number?
(�'
Street Address 7 v� l ��/��' �F° 1�u'��
City l-�� ��t-�� � State �`-'�� Zip Code ��Z (
Daytime Phone��)�`�`�'- C�Cell Phone��2� �-��vening Telephone( ) -
Date of Accidend Injury or Date Discovered � + l 1 I � �T� Time� %��Z pm
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 andlor responsible for your damages.��t Gt �C�1L�
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 di the street ❑ My vehicle was damaged by a plow
❑My vehicle was wrongfully towed and/or ticketed ❑ I was injured on City property �
�ther type of property damage–please specify R�'`��C�`_� � ��-�C�'� �p � �
ther type of injury–please specify � 't'� � ��'�"��
����u�.
I n o r d e r t o p r o c e s s y o u r c l a i m y o u n e e d t o i n c l u d e c o p i e s o f all a pplicable documen�s. ;�/t�, �
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 aze 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—nlease complete this section
Were there wimesses to the incident? Yes No Unknown (circle)
Provide their names,addr�sses and telephone numbers:
'�1'� � C�1G GLV� V l`Z ,-�4�r1�4s'-���1
Were the police or law enforcement called? Yes S� 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 diagram.
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.
Vehicle Claims—please complete this section ❑check box if this section does not apnlv
Your Vehicle: Yeaz 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
Iniurv Claims—ulease comulete this section ❑check box if this section does not avvlv
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 your Employer:
Address Telephone
�,JCheck 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 ���1 �Y
Print the Name of the Person who Completed this Form: ���"1-- �����
Signature of Person Making the Claim: , �'�
Revised February 2011 �
This April (4/17/14)we had about a foot of water in the basement. The basement has never had any
standing water in it.We have tenants that have leased space in the building for the past 20 years who
will confirm this.Sevenich, Butler, Gerlach & Brazil, Dr.O'Kane& Monssen (long term tenants) will be
sending their letters stating this to sandra.bodensteiner@ci.stpaul.mn.us.
Since the first snow melt and subsequent rains after the City replaced the sidewalk early November
2013,we have a flooded basement whenever it rains. The basement houses Haskell's merchandise as
well as medical supplies stored by the Tenants.We have paid a company each time it rains to remove
the water until we can resolve this situation. We are now beginning to see signs of mold.
I am attaching a professional assessment from Ambe, Ltd.Who inspected the building and states the
buildings waterproofing system was compromised during the sidewalk replacement. In visually
observing the building in relation to the sidewalk there is no question.
I am not attaching estimates at this time,as this is a very extensive process that will need to be reviewed
by several contractors; due to the nature of the repairs necessary which includes removing the sidewalk
that was just installed to perform the earthwork according to OSHA's requirements.
I urge you to make this a top priority in your review of claims.
AMBE LTD
BUILOING ENVELOPE CONSUITANTS
June 12, 2014
Ms. Lisa Borene
Paramount Real Estate Corporation/TCN Woridwide
3601 Minnesota Drive
Suite 925
Bloomington, MN 55435
RE: 2221 Ford Parkway
Dear Ms. Borene:
This letter will serve to confirm my recent inspection of the water intrusion in the
Haskell's Liquor Store basement. The intent of this inspection was to review the
existing structure and determine if and how moisture is infiltrating into the wall
spaces. Items observed are as follows:
1. On the south elevation of the building we observed a new sidewalk. In
conversations with both you and one of the Haskell's staff it is my understanding
that this area was dug up to allow for the new sidewalk. Prior to the installation
of the sidewalk this area did not leak. This has been confirmed by a long
standing member of the Haskell's Liquor Store staff.
2. We observed the brick wall system above the sidewalk. We find that the brick
wall to be in good condition with minor deficiencies in mortar andlor brick.
What appeared to be a crack on the southeast comer of the building was
reviewed and based on further investigation found that this is only a supe�cial
situation.
3. We then reviewed the building on the southwest comer where the EIFS and
brick meet. This area does have an opening to the possibility of moisture
infiltration but it is at the low point of the sidewalk and driveway and most
moisture runs away ftom this area. Moisture would have to be running up hill to
reach this point.
Based on our observation of the building, and based on our conversations with both
you and the Haskell's staff, we feel that during the demolition of the original sidewalk
that damage was done to the waterproofing system on the outside of the wall. Based
7201 Ohms Lane, Suite 150, Minneapolis, MN 55439
952-831-1233 •FAX 952-835-2861
www.ambeltd.com
2014 SurveysParamount-1-Haskells/jw
Ms. Borene
June 12, 2014
Page 2
on the age of the building more than likely the waterproofing system is a coal tar pitch
system. These types of systems normaily are self-healing in the heat as the coal tar
pitch stays fluid.
Based on our observation we wouid recommend that the existing sidewalk be
removed, excavation down to the foundation level be completed, and a new
waterp�oo�ng system be installed. As stated, this would cause demolition of all of the
recent repairs completed to the sidewalk, as well as around the trees that lead to the
street.
If you should have any questions in regard to this information please do not hesitate
to call upon me.
Sincerely,
��
Richard A. Grobovsky
Principal ConsultanUCEO
AMBE LTD.
2014 SurveysParamount-1-Haskellsljw