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Wohleeben, Karen RECE�VED JUL 31 2014 NOTICE OF CLAIM FORM to the City of Saint Paul, Min CITY CLERK Minnesota State Statute 466.05 states that "...every person...who clairus damages from arry rriunicipolity...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 derrianded." 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 t6at you will not be contacted by telep6one to clarify answers,so provide as muc6 information as necessary to ezplain your claim,and t6e amount of compensation being requested. You will receive a written acknowledgement once your form is received. The prceess can take up to ten weeks or longer depending on the nature of your claim. T6is 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 � Middle Initial�Last Name ��`-Z�2 V1 First Name y,�`�`"-"^ - Company or Business Name A�e 1'au aii Lisurance Compauy? Yes J 1� If Y�s,Clairn NumUer^ �' Street Address ��J �� 1 Y 1� b1�/t e��'lc ti�'�r�, ;�'�� 'lt 11� � City ��- 1��. State,� � Zip Code��`r Daytime Phone�� S�`Z`�li�Z Cell Phone o�� 7 S_O-Q`f�Z Evening Telephone(_____—j- - Date of Accidend Injury or Date Discovered C7 r� �f '� y Time �� Pm Please state, in detail,what occurred(happened),and why you are submitting a claim. Please indicate why or how you feel the Ci of Saint Paul or its employees are involved and/or responsible for your dama es. ��'^ ' • �` L}� i� , �� . 1 , a �c_E''L Ft �'/ ' �`��7 �r i'1 � ��! 52,I.i.�i`i�CtY' �Y(� l �l ' 2 1� �1 "� :;� C ri r.,^ �� Cl Y-�`� 'l. �^ '� � � ;'NS'� _ �l G;� �Y.:,y\ ��..�" S�'l' i i � . . �,. +I� �c� m�t •��r � �J-p _ °�� +� e ,tt '�;� co� .�.� . ' ;�, ev� a.� Ul-cl< <e � I IA . �'�i. - ` . �7 ,�l/ ` �� l�I�V�.� �,� . I� . �C� . .y 1 t,�. G�ls Y� r. ,n ut � +t ��- t � : � r k V�t:t � � �'' _ � 2. � a r ,. ., �� ' � v t n .,,'n t � � U c ti �� .�� - ,- � y r L C 'r'�.5 � � ��;^^�o'��.- 2ty �vt✓►��rSSc;� Y. 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 ��Iy vehicle was:�'ongful!y towed and/or ticketed ❑ I was injured on City property C�l Other type of property damage—please specify�c?�C� t��'" t��z Z c�t c� ��%P�' �' -��i � ❑ Other type of injury—please specify In order to process your claim vou need to include coaies of all apalicable 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 properiy 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 Q�Other property damage claims:two repair est ates if the damage exceeds$500.00; or the actua_ l�bills and/or receipts for the repairs;detailed list of d�aged 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—alease comnlete this section Were there witnesses to the incident? Yes No Unknown (circ}e) Provide their narqes,addresses and telephone n bers: �O�'�� ,U,"C l��-� C-C M Vhe v'�tc;� ��'c (��y, 114(�, � '�'�hS�-,S�-�'�► 4 �S(. 7�`I.C�33U 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 facility3 closest landmark,etc. Please be as detailed as ssible: If necessary,attach a diagram. �fi(e��-- �✓� ��:��-G't- i��`-i V1�1�►�n e.ha I�:, ;�v.'_ (,1�� 5��. '(�Gi,�-�Q, Please indicate the amount you are seeking in com ensation or what you would like the City to do to resolve this claimI to your satisfaction. ��wt b v t'S� e� �* � ��. ��,' vt�- c �. �� C � c�')�rC�c� �c l i�riS �'L V' � �1;.,. ..-Q I'vi f'K.(� � � . } Vehicle Claims—please complete this section check box if this section does not applv Your Vehicle: Year � Make Model License Plate Num State Color Registered Owner Driver of Vehicle Area Damaged City Vehicle: Year Make Model� License Plate Number State Co or Driver of Vehicle(City Employee's Name) Area Damaged Iniurv Claims—please comalete this section Fdcheck box if this section does not a�plv How were you injured? What part(s)of your body were injured? Have you sought medical treatrnent? 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 pag his 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 resu[t in prosecution. Date form was completed Jv�,iJ j� ,o�(� Print the Name of the Person who Completed t6is Form: __ �,�V�2 V� (�jQ 1�t`t�o L/'1 Signature of Person Making the Claim:��1�/Y� ��1�``{'M Revised February 2011 DEPARTMENT OF PUBLIC WORKS Rich Lallier, Director CITY OF SAINT PAUL Bruce Elder, Sewer Utility Manager Christopher B. Coleman, Mayor 700 Ciry Hall Annex 25 West Fourth Street Phone: (651)266-6234 Saint Paul, MN SS102 Faz: (651)298-5621 'h.tesday, July 29th, 2014 Karen Wohlleben 1829 Minnehaha Ave W Saint Paul, MN 55104 Re: Sewer Service Problem Dear Ms. Wohlleben: You recently called about a problem with your sewer service that you believe the City is responsible for fixing. Enclosed is a form for filing a claim against the City of Saint Paul. Once you complete it, please send it to the Office of the City Clerk using the address provided on the form. If you have any questions, please feel free to contact me using my information provided below. Thank you. Sincerely, �.� ��,I,�� Richard Ekobena City of St. Paul Sewer Utility Regulatory and Records Engineer Email: Richard Ekobena(a�ci stpaul.mn.us Office phone: 651-266-6253 PROPOSAL 651-774-0330 Fax 651-771-8983 E-mail cuicurella(a�me.com Date: July 29,2014 Job Name: Sewer Repair Job Location: 1829 Minnehaha Ave.West Phone: 651-755-6669 COMMERCIAL UTILITIES,INC. Email: tjpierret@cbburnet.com 1146 EAST SEVENTH STREET ST.PAUL,MN 55106 TO: Coldwell Banker TJ Pierret We propose to furnish all labor,equipment,material,and permits to repair the sar.itary sewer line for ttz: option listed below: - Option#1: Repair sanitary se�rer servic: at rye connection in street for$8,770.00. Price includes: Restoration of street. Price does not include: Any sad restoration. The following items are not included: SAC,WAC and or other connection charges,dewatering,soil correction and or replacement,removal or buried obstructions,jacking,frost charges,rock excavation,replacement of old leac'.water lines,underground irrigation lines,yard lights,compaction tests,hazardous material handling,existing service cut offs, design and plan fees. JOB PAYABLE:upon completion. All material is guaranteed to be as specified. All work to be completed in a workman like 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. �-__ __._...._ � ��r<� � �2�`� _' DATE 7/29/2014 AUTHORIZED SIGNATURE ' Note: this proposal may be wit6drawn by us if not accepted within 30 days. ACCCEPTANCE OF PROPOSAL-The prices,specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Payment will be made as outline above. SIGNATURE DATE 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 t6e 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 amounts due them from us until 120 days after completion or the improvement unless we give you a lien waiver signed by person who supplied any labor or material for the improvement and who gave you timely noticc. COMMERCIAL UTILITIES, INC. 1146 EAST SEVENTH STREET PHONE 651-774-0330 FAX 651-771-8983 cuicurellaCa�me.com July 29,2014 Job No.9571 Invoice No.6771 Karen Wohlleben 1829 Minnehaha Avenue West St.Paul,MN 55104 RE: Sewer repair 1829 Minnehaha Avenue West Furnished labor,equipment,material and permit to repair sanitary sewer service at wye connection in street at the above mentioned project. AMOUNT DUE: $8,770.00