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Saum NOTICE OF CLAIM FORM to the Cit��O��� Paul, Minnesota Minnesota State Statute 466.05 states that "...every person...who claims damages f om any municipality...shall cause to be presented to the governing body of the municipality within I80 days after the alleged loss or inj��a�rc�e��notice stating the time,place,and circumstances thereof,and the amount of compensation or other relie emanded." T�� �g c-�� Please complete this form in its entirety by clearly typing or printing�ilr°a�siv�r"� ach question. If more space is needed,attach additional sheets. Piease 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 �/ v �� Middle Initial C Last Name ��� � Company or Business Name Are You an Insurance Company? Yes No If Yes, Claim Number? Street Address �� � g ����� � v�" � City �� �� (�., � °� State i�� Zip Code �J�l1l Daytime Phone ��� �-�.S Cell Phone 6Sl $�-�b�O� Evening Telephone 6S`/ 78- 7�58� Date of Accidend Injury or Date Discovered ������� Time o?-�� 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.P��.�T �R�� lv4�E� ��Z /.?��.ui ��AA��e�d SE�1G� o.�/ �G /I�S/ pi�oO,�'•2> ��A�d �'G�S ��VM � �lL .¢T�"C � � ��t�' �o� o,v ' �r�r«-�a GA�csE Gvt�rs �-.cr ��e .,A-,�r .� �.I� /yJ /yJ /POa�I��.D D �/�L'�.d .1/.G Td�� �'i/� O���Qf uL.Gc��S a 1.�_ d�..v �� ri �o .�,�T,QUCr�a � To v s>�,� �•Q �9 y po�. o .Gr�7"6'.�ET,�Sy"�i,?.9�T�S .� a�.GE.es l/,vnG '��s d'�.2�-�: 2 � Tv ��i2 7�� ,�� Tv E .�rrd,� ,ea��' Et� �-,,,� �',�,CGc2J.�va- ��.�l,�T6 , �'!�",2uc7�,YJ y :�,e,41, .�S"'G�r, �'���t[, GU.y-T�.c? Please check the box(es)that most closely represent the reason for completing this form: G ii�1y vehi�ie was damaged in an accide�►� ❑ iviy vel�icie was datr�aged during a�o� ❑ 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 o}�City property �/�T ,�(Other type of property damage—please specify/���'JG G�,9,P�46,� �9� �/����`d �J%�� ��.�-�� ❑ Other type of injury—please specify -TOU%t� In order to process your claim���u need to include copies 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 are encouraged to keep a copy for yourself before submitting your claim form. O Properly 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 }8f 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—alease comnlete this secHon Were there witnesses to the incident? Yes No Unknown (circle) Provide their names, addresses and telephone numbers: ,(/� � ,9�L- Zl�9T.��2 .�0� �j��-- Z�p— �v�1�0. �G�D G�/T� �.�r1.e�T€,e � DG?��2 �/�� .��1�5" Were the police or law enforcement called? Yes � 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. I necessary, attach a diagram.�318 C/3S� ,4tJ�. � /�'liwo- /�'l�. C'�i�s�o ,�;� l�J,9°r�,¢ T���,rz f��i�2 p.v i�uu9�,e � 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.l' i CUJGL ��Lr '�-ST L/n OdF��ST/��� �' a,� 7� 4.�TEt�oy'�t,�2 ,a,�',�' v /j1 ,�ooE.e Vehicle Claims—please complete this section ❑ check box if this section does not avnlv 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 Injury Claims please complete this section ❑ check box if this section does not annlv 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 i�id you miss work as a resuit 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 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 7���1� Print the Name of the Person who Completed this Form: ��� � - � � Signature of Person Making the Claim: Revised February 2011 Proposai M , � MANN BUILDERS INC• COMPLETE 1170 15th Street West•Hastings,MN 55033 CONSSERVICOES Business: (651)480-1577•Cell: (651)210-8363 MN License#BC 20323207 PRO UBMITT D TO PHONE DATE U �-57$� gS - 3�-�Ot 2 STREET JOB NAME ' ' CITY STATE and IP CODE JOB LOCATION 'M O 1 S DATE OF PLANS JOB PHONE We hereby submit specifications and estimates for: -�-1 N � Sh� � CI � �i���r.�I L�� � ��:�-re� si,,�,id �s ��e� �a� �c-�S7�� �1 l�s � i-�e.l-� ��r-- � � ' ' %1.�ST"L� f''XS����' S����(.' 'S -�o iw�i'C�-1 ��C�S' i r�4 v� �o G�UST (�_�L l C.� (71- Ctc�O 1� ������� We Pt'OpOS2 hereby to furnish material and labor—complete in accordance with above specifications,for the sum of: � dollars($ '° )• Payment to be made as follows: One half down at time of acceptance with balance due in full upon completion unless financing is arranged. 1.5% Interest on unpaid balances. NOTICE TO PURCHASER f/ A.DO NOT SIGN THIS BEFORE YOU READ THE WRITING ON THE Authorized �/ REVERSE SIDE,EVEN IF OTHERWISE ADVISED. Signature � B.DO NOT SIGN THIS IF IT CONTAINS ANY BLANK SPACES. C.YOU ARE ENTITLED TO AN EXACT COPY OF ANY AGREEMENT YOU Note:This proposal may be SIGN. withdrawn by us if not accepted within � days. YOU,THE BUYER,MAY CANCEL THIS PURCHASE AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY AFTER THE DATE OF THIS Signature PURCHASE.SEE NOTICE OF CANCELLATION ON REVERSE SIDE OF THIS PROPOSAL. 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PC��StJANT TC? Tk-!!S ��#������dT ,R3�E C���[Vl�t� IIUiP1�C}V����IT. €�_'`.��7" i�4�E�3�"�€`��3�l��. 1048 B Payne Avenue �� St. Paui, MN 55130 ,�S'ZTP� IOR (651) 774-5582 E��"" RIORS Superior Classic, Inc. MN Contractor#20219220 William Mellgren JACK �/au a% (651)248-4406 2318 CASE AVE E MAPLEWOOD MN (>S!-� 7S� � 7�K� Item Quantity Amount Total REMOVE SHINGLES AND FELT 15 $45.00 $675.00 REMOVE AND REPLACE ALL FLASHINGS 0 $0.00 $0.00 INSTALL ICE AND WATER AND LIFETIME $0.00 $0.00 WARRANTY DURATION O,C. SHINGLES 16.66 $280.00 $4,664.80 0 $0.00 INCLUDES ALL CLEANUP AND DEBRIS 0 $0.00 $0.00 REMOVAL 0 $0.00 $0.00 0 $0.00 $0.00 0 $0.00 $0.00 0 $0.00 $0.00 , $5,339.80 PLUS COST OF PERMIT � ( SHINGLE PRICES ARE INCREASING 10% I AS OF 5/1/12 � THANKS BILL