Gardner-Taylor, April ����1\,��D
JUL 14 20��# � __
NOTICE OF CLAIM FORM to the Cit of Saint Paul, Minnesota
C I TY C��R'K'� �����° .. .
Minnesota State Statute 466.05 states that "...every person...who claims damages from 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 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 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 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 ,-t-t7 r 1' Middle Initial Last Name �'�'�(�1��r — I C�i.�� S�
Company or Business Name
Are You an Insurance Company? Yes/ 10 If Yes, Claim Number? �
Street Address /,�,��2. <SC•��t�+�1— ttV�
City LUt.- t'u-.�,�-� State �� Zip Code SS� � �
Daytime Phone(�Z-�Cell Phone( ) - Evening Telephone(�� 1`�i �
Date of Accidend Injury or Date Discovered '�un� Jt� Time / .Dl� am 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 and/or responsible for your damages.
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Please check the box(es)that most closely represent the reason for completing this fo� ���
❑ My vehicle was damaged in an accident ❑ My vehicle was damaged during a tow
❑ My vehicle was damaged by a po±hole or condi±ion�f rhe strPet L� My vehicle�vas damaged i�y a plo�v
❑My vehicle was wrongfully towed and/or ticketed ❑ I was injured on City ploperty J
� Other type of property damage—please specify /-fvUS� �v�er5 g�, 1���-��a;.�a� �a�rnade0' ��-'�'
❑ Other type of injury—please specify `J�'� ��I
o� hE�uS«•
In order to process your claim vou need td 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: 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 witnesses to the incident? es No Unknown (circle) /
Provide their names, addresses and telephone numbers: L[�r� ,�,�i ,�,� ��/l�oi� ;-t -�/�rJ� dv/' ��,
�� 1 �-Iv�� � �Ta�./r��
Were the police or law enforcement called? Yes No 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,
clo est landmark�etc. Please be as detailed as possible. If necessary, attach a diagram.
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Please indicate the amount you are se��n��ompensation or what you would like the City to do to resolve this claim
to your satisfaction. �1�
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Vehicle Cl�ims—pleasecomplet�this section '`� �check box i��is section does not applv
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
Iniury Claims—please comnlete 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(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
�Check here if you are attaching more pages to this claim form. Number of additional pages�p�G�-r���
� �5�+ ma-�CS
By signing this fornz,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 %��N // �-���/5'
Print the Name of the Person who Completed this Form: /-�'/�r"f � (,�c.�vt�r ✓�y��
Signature of Person Making the Claim: �l� ,�� �
T
Revised February 2011
`\;� SHERIDAN SHEET METAL COMPANY
� 4108 QUEBEC AVENUE NORTH PROPOSAL
NEW HOPE,MN 55427 Date 7/7/2014
(763)537-3686 Fax (763)537-8139
Proposal# 44777
Proposal Submitted To: Job Location: (808)741-9303
APRIL TAYLOR APRIL TAYLOR
1222 SCHEFFER AVE 1222 SCHEFFER AVE
ST PAUL,MN.55116 ST PAUL,MN 55116
Sales Person BILL
Description Total
REMOVE EXISTING GUTTER AT FRONT ENTRY 8c HOUSE FRONT LEFT HAUL AWAY.REMOVE
EXISTING GUTTER HELMET&.DISPOSE.
SUPPLY&INSTALL 5"K STYLE 26 GAUGE PRE-FINISHED VVHITE STEEL SHERIDAN GUTI'ERS& 566.00
RE-CONNECT UP EXISTIl�iG DOWNSPOUTS
PAYMENT TO BE DONE AS FOLLOWS:
25%DOWN PAYMENT PRIOR TO WORK BEING STARTED AND BALANCE DUE UPON RECEIPT OF
INVOICE
00
� � ��c�rf� V �f�e � j��P (�C �'�n P � ��� �
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$566.00
PRE-LIEN NOTICE � ('jv��l/11y�, �i
(A)ANY PERSON OR COMPANY SUPPLYIl�IG LABOR OR MATERIALS FOR TffiS IlVIPROVEMENT TO YOUR
PROPERTY MAY FILE A LIEN AGAINST YOUR PROPERTY IF THAT PERSON OR COMPANY LS NOT PAID FOR
THE CONTRIBUTIONS.
(B)UNDER MINNESOTA LAW,YOU HAVE THE RIGHT TO PAY PERSONS WHO SUPPLIED LABOR OR
MATERIALS FOR THIS IlVIPROVEMENT DIRECTLY AND DEDUCT THIS AMOUNT FROM OUR CONTRACT
PRICE,OR WITHHOLD THE AMOUNTS DUE THEM FROM US UNTII.120 DAYS AFTER COMPLETION OF THE
Il�IPROVEMENT UNLESS WE GIVE YOU A LIEN WAIVER SIGNED BY PERSONS WHO SUPPLIED ANY LABOR
OR MATERIALS FOR THE IlVIPROVEMENT AND WHO GAVE YOU TIlVIELY NOTICE.
ANY ALTERATION OR DEVIATION FROM TI-IE ABOVE SPECIFICATIONS INVOLVING EXTRA COSTS WII,L BE EXECUTED ONLY UPON WRITTEN ORDERS AND WII.L
BECOME AN EXIRA CHARGE OVER TT�ABOVE ESTIIvfATES. ALL AGREEMENTS ARE CONTINGENT UPON STRIKES ACCIDENTS OR DELAY BEYOND OUR CONTROL.
OWNER TO CARRY FII2E,TORNADO AND OTI-IER NECESSARY INSURANCE. OUR WORKERS ARE FULLY COVERED BY WORKMANS COMPENSATION INSURANCE.IN
THE EVENT OF DEFAULT IN Tf�PAYMENT ARRANGEMENf HEREIN,SHERIDAN SHEET METAL COMPANY SHALL BE ENTITLED TO RECOVF.R"I'f�PRINCIPAL
BAI.ANCE PLUS INTEREST AT TT-IE RATE OF 18%PER ANNUM PLUS COId.ECTION COSTS INCLUDING ATTORNEY FEES.
ACCEPTANCE OF PROPOSAL: 'THE ABOVE PRICES, SPECIFICATIONS,AND CONDITIONS ARE SATISFACTORY AND
ARE HEREBY ACCEP'TED. YOU ARE AUTHORIZED TO COMPLETE WORK AS SPECffTED. PAYMENT WII..L BE
MADE AS OUTL$iED ABOVE.
DATE OF ACCEPTANCE: SIGNATURE: �
THIS PROPOSAL MAY BE WITHDRAWN BY US IF NOT ACCEPTED WITHIN 30 DAYS. B�
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�I� L �� � ��� � 1� 1��, W E�T�lUAY EXTERIORS
Worry-proof buiidings and homes since 1938 ' Worry-proof buildings and homes since 1938
Owner: J� � � ' � Date: ��� �— Z a��
� ZZZ SC�n� + � v Primary Phone:
, u✓ Secondary Phone: �l5 � 7`7 r � ��
It is our pleasure to provide you our proposal for installation of seamless gutters AND/OR downspouts on the p� r
�a5�
C,G1.�n�i' as per diagram below,excluding ��e �o S� ,located at
q S,�v� ��r�S S . We offer you not only fair and competitive pricing,but also experienced,qualified per-
sonnel,and full-time supervision of the ent�re pro�ect. We guarante quality workmanship with our commitment to excellence and professionalism.
� Remove and haul away old gutters and downspouts. d- ���""'�� ,
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�Install new aluminum gutter apron under shingles and into the gutter O reuse existing apron�
�] Insta 5'l�' R 6"heavy a aluminum,pre-finished gutters,secured with heavy duty concealed hangers every 24"to 32"where possible.
m Install 3"x4" R 2"x3"pre-finished downspouts with extension.
❑ Install valley splash guards. o
° � . � Downspout Color: ���
� Gutter Color: w��
� Install ✓ ��-t r � ,M/ gutter covers. C lor:T`r '�o w P - �l ✓1 �. 1a e►�c
n I l/ � W S�-Or1 r�T rt-��5�� �l gV 1�/�n�� D�1t�/ �N�r� ���
� Other• K P A�Ct cP
❑ Other:
!�Q�Any hidden deterioration behind existing gutters,including wood structure and fascia will be repaired at a cost of$85.00 per man per hour plus the
�� cost of materials above the contract price. Walker Roofing Company/Westway Exteriors will norify you of any additional charges.
� Remove all equipment and materials from job site when completed;clean up and haul away all job related debris from the premises.
GUTTER DIAGRAM
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LEGEND: Gutter pownspout � Elbows A or B Extension and Lengt6 —� Power Lo�i o
TOTAL INVEST ENT AS DESCRIBED ABOVE:
$ *
*This price includes all applicable discounts and coupons.
PLEASE INITIAL: OPTION:
for the additional cost of$ above the contract price.
GUARANTEE: There is a conditional limited lifetime warranty on all aluminum products. Due to extremes in temperature we are unable
to guarantee caulking for more than one year. For several reasons the gutter may not drain 100%. One example may be aesthetics.
PAl'MENT:A 1/3`�down payment is due upon acceptance of this proposal. Full payment is due upon completion;.8%interest due per month on
' past due accounts.
PLEASE CHARGE ❑ -❑� Cazd#: Exp.Date: 3-Digit Code:
NOTE: This proposal may be withdrawn by us if not accepted within 30 days and price is subject to manager's approval for 7 days after customer
� signature.
Warrantv Right: In addition to any written warranty we may provide you,you acknnwledge receipt of a capy of the warranty provided
pursuant to Minnesota Statutes Chapter 327A whic6 may also apply.We hereby disclaim all warranties,express or implied,contract claims,
-- - . . .. .. . . ._ �—'------'-------`--__�a_a--^'•.:a�....:u,.......a:..e..,:*6:..e.o mnn4l�a frnm}ha d9ta nf disrnvnr'v
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NOTICE:
(A) ANY PERSON OR COMPANY SUPPLYING LABOR OR MATERIALS 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 MATE-
RIALS FOR THIS IMPROVEMENT DIItECTLY AND DEDUCT THIS AMOUNT FROM OUR CONTRACT PRICE,
OR WTTHHOLD THE AMOUNTS DUE THEM FROM US UNTIL 120 DAYS AFTFR COMPLETION OF THE IM-
PROVEMENT UNLESS WE GNE YOU A LIEN WANER SIGNED BY PERSONS WHO SUPPLIED ANY LABOR
OR MATERIAL FOR THE IMPROVEMENT AND WHO GAVE YOU TIMELY NOTICE.
WALKER ROOFING COMPANY INC./WESTWAY EXTERIORS
STAT� OF MINNESOTA LICENSE ID #4229
• WE WILL SUPPLY ALL NECESSARY MATERIALS,EQUIPMENT AND LABOR TO COMPLETE THE ABOVE DE-
SCRIBED WORK. WE WILL PROVIDE A LIEN WANER AND A CERTIFICATE OF INSURANCE UPON REQUEST.
WE PROVIDE THE BUILDING PERMTT. ANY DEBRIS LEFT FROM THE JOB WILL BE CLEANED UP AND
HAULED AWAY FROM THE PREMISES.HAZARDOUS MATERIAL REMOVAL AND DISPOSAL COSTS WILL BE
THE RESPONSIBILTTY OF THE OWNER. ALL WORK IS WEATHER PERMITTING.DUE TO MINNESOTA
WEATHER,WALKER ROOFING COMPANY/WESTWAY EXTERIORS CANNOT GUARANTEE AGAINST ICE
BACK UP AND ICE DAMS THAT MAY CAUSE LEAKAGE.
� ALL MATERIAL IS AS SPECIFIED,ANY DEVIATION FROM THE ABOVE SPECIFICATIONS INVOLVING EXTRA
COSTS WILL BE AN EXTRA CHARGE OVER AND ABOVE THIS ESTIMATE. SPECIFIED WORK AND QUOTED
PRICE IS SUBJECT TO CHANGE UPON DISCOVERY OF ANY HIDDEN DEFECTS. INSTALLED MATERIALS BE-
COME RESPONSIBILITY OF OWNER. SOME DEBRIS DIRT,GRAVEL,TAR,DUST,ETC.,MAY FALL THROUGH
GAPS IN ROOF DECK. PLEASE TAKE PRECAUTIONS TO MOVE OR COVER IMPORTANT ITEMS.
• OUR COMPANY HAS THE RIGHT TO ORDER EXCESS MATERIAL. THESE MATERIALS WILL NOT BE
CHARGED ABOVE THE AGREED UPON PRICE. ALL EXCESS MATERIAL BELONGS TO OUR COMPANY.
• WE ARE NOT RESPONSIBLE FOR DAMAGES FROM FIRE, WINDSTORM,OR OTHER HAZARDS THAT ARE
NORMALLY COVERED BY HOMEOWi+1ER'S�i . -
• SUPPLEMENTS PROVIDED BY THE INSURANCE COMPANY FOR ADDITIONAL WORK ARE TO BE PAID TO
WALKER ROOFING COMPANY/WESTWAY EXTERIORS.
• WE ARE NOT RESPONSIBLE FOR DELAYS CAUSED BY(i)ANYTHING DONE OR NOT DONE BY YOU,OR ANY-
ONE HIRED OR EMPLOYED BY YOU,(ii)CHANGES IN THE WORK,(iii)ANY WORK STOPPAGE PERMITTED
BY THIS AGREEMENT,(iv)ANY ACTS OF GOD,(v)LABOR DISPUTE,(vi)FIRE OR CASUALTY,(vii)DELAYS IN
MATERIAL DELIVERIES,(viii)ADVERSE WEATHER CONDTTIONS,AND(ix)OTHER CAUSES THAT WE CAN-
NOT CONTROL.
� IN THE EVENT THIS OBLIGATION IS PLACED WITH AN ATTORNEY FOR COLLECTION,OR TO ENFORCE ANY
PART OF THIS AGREEMENT,THE BUYER AGREES TO PAY ALL COSTS INCURRED,INCLUDING COURT
COSTS AND REASONABLE ATTORNEY'S FEES.IF WE FILE A MECHANIC'S LIEN AGAINST THE PROPERTY,
YOU AGREE TO PAY THE COSTS OF PREPARING,SERVING,AND FILING THE MECHANIC'S LIEN,INCLUD-
ING REASONABLE ATTORNEY'S FEES. IF ANY PAYMENT REQUIRED BY THIS AGREEMENT IS NOT RE-
CEIVED BY TfS DUE DATE,YOU AGREE TO PAY INTEREST ON THE UNPAID BALANCE WITHIN THE LIMITS
ALLOWED BY LAW,AT THE RATE OF 8%PER YEAR.
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