Merberg, Miriam K�C�I,�'�D �
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NOTICE 4F CLAIM FORM to the City of Saint Paul, Minn�e,s��t�a CLE�K ;
Minnesnta State Statule 466.05 states that "...every person...who claims clamages frorn any municipality...shall cause to be presented to the
governing body of the municipaliry within I80 days after the atleged loss or injury is discovered a notice szating the time,place,and
circumstances thereof,and the mnount of compensatiore 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 w11 not be contacted by telephone to clarify answers,so provide as
much i�ormation 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 sometlung 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 ��l�'1 (V Lgy�, Middle Initial�Last Name
Company or Business Name
Are You an Insurance Company? Yes No Yes,Claim Number?
Street Address � �
City �'r ��-�-� State 1/Y1�� Zip Code S C"D Z,
Daytime Phone(�S )��d Zs�ell Phone(��'�3��vening Telephone((eS()�-2�SZaS j
Date of Accident!Injury or Date Discovered ��Z� Time � Pm
Please state,in detail,what occurred(happened),and why you aze subtnitting a claim. Please indicate why or haw you
feel the City of Sain aul or its employees aze involved and/or responsible for ur damages.
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LO V�'
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
❑ My vehicle was wrongfully towed and/or ticketed ❑ I was injured on City property
��ther type of property damage—please specify - � S�e � ���)
❑ Other type of injwy—please specify
In order to process your claim vou need to include couies of all apnlicable 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 aze encouraged to keep a
copy for yourself before submitting your claim form.
O Property damage ciaims 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
C�Sk„5 O Towing claims: legible copies of any ticket issued and a copy of the impound lot receipt
�ther property damage claims:two repair estimates if the damage exceeds$500.00;or the actual bills
��j,F� ' and/or receipts for the repairs;detailed list of damaged items
���'``�,� O jury claims: medical bills,receipts
� '�'J fc�hotographs are always welcome to document and support your claim but will not be retwned.
\��� Page 1 of 2—Please complete and return both pages of Claim Form
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Failure to complete and return both pages will result in delay in the handling of your claim. �
All Claims—nlease comnlete this section �
Were there wimesses to the incident? es� No Unknown (circle) �L
Provide their names,addresses and telephone bers: �'�. ��;��-� �'�f ����'`� ,
�
Were the police or law enforcement called? Yes No Unknown (circle) t{-�r
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 landmazk,etc. Please be s detailed as possible. ff necessary,attach a diagram.
�-� c R�, � ` 1 S �r�-
Please indicate the amount you aze seeking in compensauon or v�hat you would 1Ne���y�t��to reso�this claim
to your satisfaction. �
� a
Vehicle Claims— lease com lete t 's s ction ❑che k box if this section does n t 1
Your Vehicle: Year Mak Model
License Plate Number State Color
Registered Owner
Driver of Vehicle
Area Damaged
City Vehicle: Year Make odel
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
In'ur Claims— lease com te 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 your Employer:
Address Telephone
�C` heck here if you are attaching more pages to this claim form. Number of additional pages �.
r
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.
Submitti�g a false claim can result in prosecution. Date form was completed � � � '����
Print the Name of the Person who Compl�ec ' 'o�� r�
(
Signature of Person Making the Claim.�
Revised Febmary 2011
I
� DEPARTM�TIT OF FIltE ANB SAFL''IY SERVICFS
Timo�hy M.Butler,Fire Chfef
sw�„r CITY OF SAINT PAI3L �SRandatphAvenue Telephone:651-22�-7811
PAU L
� SaintPaut,MNSSItl2 Facsimrle:651-228-b255
Chrtrtopher B.Co%amart,Mayor
��
July 31,2014
To Whom It May Concern:
The Saint Paul Fire Department responded to a report of a dwelling fire at 424 Goodrich Avenue,on
July 21,2014,at 0030 hours. At the time of the incident,fire personnel attacked a portion of the fire
via the yard at 421 Banfil,damaging two fences.
Saint Paul Fire Investigators determined the classification of fire cause to be incendiary. The damage
estimate regarding this fire is approximately 5330,000. The full investigation report is not available
at this time due to active investigative status. The fire department's incident numher is#i 4-21997.
if you need any more information regarding this incident,please contact our Fire Investigation's
Office at 651-228-6264.
Sincerely,
��J'/��'J'
S on Urhammer
Office t�ssistant N -Investigations
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Local option euyincss na�m 1if appiLCable) Area Cade Hwne 1RrMer
❑Check This Eoz iE � I I � � ' � .
9apec addreee as Mr.,Ne., Mre. P�r9G Ra�oe MI i.aBt 718ae bUfYix
incfdent location. ' � I . . 1 u
Then ekip the three
dupliCate atWzeas y�p�r prefix Street or AigMray �T'�t 1YPe 8utfift
lines. t
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�i�re people invalved? Check Chie box and attach Supplenental Forma (1�FIR9-1S) ss AACeBHAY]�
K 2 o�vn.er s� as pei'son imalvcd?
2hrn check thi.s bwc amd akip I I ' . f — ��"�J
The zeet oi thia secti�.
t,acal Optioa Businesa name (if Applicabl¢) Area Code 9hone Webec
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❑ CtseCk tAfa 6ox it F9z..M9., Mrs. Nirat Naam mZ �ax �� �Et�
same addreo� as
inci4en[ location. ( ' I ' � I
'34�en ekip the three 1. �� gtree� SuFfix
duplicate addreee �r Pretix Street oz Aighway
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Poat Office 8w[ �•��i��� City
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State Eip Oode
j� Remarks
uaal aption
FIRE PSRSONNEL RESPOTJDF3D TO A HOUSE FIRE IN A TWO AND A HALF STORX DWI3I,LING WITH TWO ELDERLY
MALES TRAPPEA. E:NGIN� #10 ARRTV�D ON SCT3IdE AND RPsPORTSD HEAVY FIRE SHOWTNG ON THE CHARLI73
SIDE WITH TWO PEQPLE ON THE ALPHA SIDE PORCH ROOF. ENGZNE #10 LADDEREb THS ALPHA SIDE AND
12E5CU$D THE TWO P$OPLE. ENGINS #10 TIiEN MADB SNTItY INTO THE SSCOND FLOOTt WSNDOW WHERE THBY
FOUND AND RESCUED A SECOND VICTIM.
ENGINE #5 ARRIVEA ANB STRI3TCHED A HOSFs LINE TO TfiF SECOND FLOOR WFII3RB THEY FJCTINGUISHEA THE
FIRFs ON THE SECOND FLOOR. SQUAD #3 ARRIVED AND STRSTCHED A HOSE LIN� TO THE FIRST FLOOR AND
SXTINGUISHED THE FIRB ON THE FIRST FLOOR. PNGIZdE �}10 THEN PIILLED A HOSB LINE TO TH$ CHARLIB
SIDE GARAGE FOR $XTYNCUISHMENT. A PRIMARY AND SBCONDARY S13ARCH WAS CONDC7CTED AND WS
OBTATNF3A AN ALL CLEAR TN THE F.NTIRE STRUCTURI3.
MEDIC #7.8 A1�1D MSDTC #4 TRA23SPORTBD ONE VICTIM EACIi TO REGION'S HOSPITAI, AND THE THIRD PSRSON
DID NOT NEED TO BE TRANSPORTED. XCLL ARRIVSD AND SHUT THS C3AS QFF AND COT THR ELECTRICITY
AT THE POLE.
TWO WATER SUPPLIE3S WER$ ESTABLISH1iD, VENTILATION, AND OVERHAUL COMPLETED. FIRE INVBSTIGATOR
NOVAK ARRIVED ON SCENE AND CONDUCTED AN INVBSTIGATI013.
DURING FIRE SUPPRESSION QPERATIONS, SQUAA #1 STRSTCHED A HAND-LINE FOR FIRS EXTINGUZ3HMENT
THROUGH THE CHARI�ZB SIDE. SQUAD #1 NEIDED TO STRETCH THEIR LINE THROUGH 42l BANFIL AND IN
THE PROCESS, DAMAG�D TWO FENCBS. THE ACC£sSS HAD 4'O BS MADE 'THROUGS 421 BANFIL AS THFs ALPHA
51D$ OF THE PROPERTY AT 924 GOODRICH HAD TO MANY H74ZP.RDS TO MAKE ACCBSS. THE DAMAGB TO THE
FENCE WAS NECESSARY FOR FIRE EXTINGUISHMBN'P.
L Authorization
�4125 � ( INKS. BARTON D � L � �C2 � 07 22 2014 ;
lbnth Day 1eaZ i
position or raek nsaigm�ent �
OEficer in charye ID signature
`�1eC�` � �412 5 � �INKS. BARTON D � ( � �C2 � ��J U 2014 �
sox iP Ysar �
aa OfficOr�r�ipg report TD Signature Po�ition oz zank Asei�eent 1Wntli Day
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SuinC Paul Pire DepaYtmenl 62230 Q7/21/2019 14-0021997 'I
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Photos of the broken fences at 421 Banfil Street,due to the firefighters for the fire at 422 i
Goodrich. �'
1.Back Fence-2 views
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