Tronstad, Daniel F��:�.��.�o.��_�
SEP 'S 2��4
NOTIC� O� CLALM FORM to the Citv af Saint Paui, M�np�c►�L�:.��
Ivfbuaesora State Srazute 466.05 stazes that °...evern person_..who claims damages irom am mrocicmalin.._s'hall cause zo be presentec to the
governirzg bod} of the municipalit} within 180 days afzer rne aldeged loss or injurn is discovered a notice statinp the time,place,and
circumstances thereof and rhe amount of compensation o*otner reiiej demanded.°
Please compjete this form in its entiret��b�ciear}f tvping or prinfung vour answer to eacb Qnesbon. If more sgace is
needed.attach addifooaal sheets. Please note that yon w�11 not be contaeted b�telephone to clarif�answers,so provide as
much informabon as necessar�-to egplain vonr ctaim,and the amount of compeusation beiug reqnested. You will receive a
written acl�nowlecl�ement once vonr form is received. The process can take np to ten weeks or louger depenciing on the
aature of vonr c�aim. This form mnst be signed,and both pa�,Les completed. If somethiug does not applF,write `N/A'.
SEND COMPI�ETED FORM!�N�D O'I�R D4CL�1V�NT'S T�O: CITY CLERK,
15 WEST KELLOGG BL�-D, 310 CITY H_ALL, S a.Il�'T PAUL, 1_YLN 55102
First Na.me �ftiJ 1�� Middle Init�al�Last Name��N S 71��
Company or Business I�ame
Are You an Insurance Company? Yes No If Yes,Claim Number?
Street Address �b S 3 �D��,G�Y�.4, ���-
�In� ��• ��v l State I�`v Zip Code S sl 1 ll�
Daytime Phone(�,��- UJU�Cell Phone(b�Z )�/�)-���venina Telephone c1� ��- 8���
I?ate of Accidend Injury or Date Discovered��V � .��� Time��V1!� am/�
v
Please state,in detail,what occuaed(happened), and why you are submitting a claim.Piease indicate why or how you
feel the Ciry of Saint Paul or its employees are involved and/or responsible for your damages. �n�-�i.c�CG!
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Please check the box(es)that most closely represent the reason for completin�this form:
� My vehicle was dama�ed 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
p My vehicle was wronr•fully towed and/or ticketed ❑ I was injured on City propertv
�1 Other rc�pe of property damage-please specify .�PI^�v►� IG���2. �}'2�5 � ��n�5 �r►�.���'4�`n
❑ Other type of injury-please specify
In order to process your claim vou need to include covies of ail appticable documents.
For the claims n�pes ]isted below,please be sure to include tbe documents indicated or it will delay the handling of
vour claim. Documents R�II.L NOT be retur,.ied and become the propem�of the City. You are encouraaed to keep a
coPS�for yourself before submitting your claim form.
O Property clamaQe claims to a vehicle: two estiu3ates for the repairs to you:vehicle if the ciaacaae exceeds
�SO�.Oa; o:the actua:bills and/or receints for the regairs
O Towin�ciaims: le�ble copies oT an�-ticket issued and a copy of the impound lot receipt
!� Othe:prope�- c3amage claims: two repair esti�ates i.`the damage exceeas �SOQ.OQ; or the actual bills
and/o:receipts fo:the regairs;detailed ust of clama=ed items
O Iniur��claims: medical bills,receipt
O PhotoP:aphs are alwa��s welcome to document and support you:claim but will not be returned.
Page 1 of 2-Please complete an�d return both ga�es of C�aim Form
Failure to complete and retuc-n both gages will result in de}a`in the ha.ndiing of your e�aim.
�11 CFaims-viease comnlete this section
Were fnere wimesses to the in�ident? Yes No lin�own (circle)
proviae t'tieir aan�es, addresses and telepbone numbers: v 4 r� ��T �P���� ��"�`�- (�S�
t�J��-��2 �cn-c �S £',�noiED i� � � �.rc�. 2�r�hkt<,�- Itic�d�c �,�' w����'f", r��l
�✓ere the police o-lac��enr'orcement called? Yes �� lin�own �circiej
I yes, what degartm�n: or�ency? Case� or report�
R'h�re dic the ac�ident or iniu.-��ta�e place? Pro�nae str��adaress. cross stree�, intersection,name oi gar�or iacilit��,
ciQS�st landmar�, etc. Piease be as deta.iled po �J I. ���ssa.-�,��ch���am.
��u'�_ RD �Ct � ,�-
Piease indicat°the amount you are sA.�l:in�in compensation or what you would Ii.ke the Ciry to do to resolve this claim
to vour satisraction.
�-ehiele Claims please comvlete this section �check box if this section doe�not a��lv
Y our V ehi cle� Y ear Make M odel
License Plate Number State Color
Resistered Owner
Driver of Vehicle �
./�rea I?amaged
City�'ehicle: Year Make Model
License Plate Number Staxe Color
Driver of Vehicle(Ciry Employee's Name)
Area I?amaged
InjurF- Claim�c-nlease comv)ete this section �check box if this section does not applv
How were yov 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))
_?�ame of your Em�loyer: - - -- — — -
Address Telephone
�heck here if vou are attaching more pages to this claim form. Number of acidiiional gages ( .
By signing this form,you are sta.ting that aZl infornw.�.on 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. I?ate form was compietec3 -! ) �� '�
l-
Print the Name of the Person who Completed o�: ���EL ���s�
Signature of Person Nfalang the Claim:
Revis��e�an 2011
= Invoice
LANDSCAf�ING �
IRRIGATION, ING
aiso co�,�nouse si�a.ct. '���Qatea � = r�t��r+�i�e�#�:�,E
Inver Grove Heights,MN 55077 9/10/2014 2014-3369
(651)457-6037 FAX(651)457-4430
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Bill To 9�ionoia Due on receipt
Dan Tronstad �����,�� �.�� � � ���„�� � � ; ,� a
1653 Bohland Ave. � - ��� �a � ��� ��� � �.: �� � �'
St.Paul,MN 55116 �� �� � � � f���� � �
Dan Tronstad (651)695-8112
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1 Service call and 30 minutes labor 7-31-14 85.00 85.00
0.5 Labor 65.00 32.50
10 Funny pipe 0.89 8.90
3 FP fittings 0.75 2.25
5 1" clamps 0.69 3.45
3 1"x FP coupling 4.22 12.66
1 1" coupling 2.84 2.84
3 RB 5004 rotor 19.95 59.85
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Sales Tax (7.125°/a) $o.00
We appreciate your business. If you would like to make payment by phone Payments/Credits $0.00
with a credit card or have any other questions please contact us at(651)
457-6037 or email us at info@wagnersod.com Balance Due $207.45
info@wagnersod.com � www.wagnersod.com � www.wagnersodirrigation.com
"Beautify with Family Traditio�"