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NOTICE OF CLAIM FORM to the City of Saint Paul, lVTinne�i�a
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Minnesota State Stattcte 466.05 states that "...every person...who claims damages from any mun:capality...shall� e to s�nted 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."
Ylease complete this form in its entirety by clearly typing or printing your ans�ver to each question. If more space is
necded, attach additio���1 sheets. Please note that you«�ill not be contacted by telepho�e to clarify answers,so provide as
uluc�t in(ormation as necessary to explain your claim, and the amount of compensation being requested. You will receive a
�v►•itten acknowledgement once your form is received. The process can take up to ten weeks or longer depending on the
nature of,�our claim. T:�is form must be signed,an�iloth pages compteted. If sc��.aething doe�n�t apply,wrifc`h`/A'.
SEND COMPLETED FORM AND OTHER DOCUMENTS TO: CITY CLERK,
15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102
First Name YA�JL Middle Initial � Last Name V Ce,�
C':�mpany���,�I3t,,�iness Nam:. _����Q�e_� �.(.�
_------- -__---- ----- -----
�--_---_____.__.
Are You an Insurance Company? Yes/� If Yes, Claiin Number?
Street Address 1 Qj,3 � .Sit,t�rf ry��f �//E
City �j" �jQ�J L State /�9/V Zip Co��
Daytime Phone( 5�2)�-/2S/ Cell Phone /Z S7 -3l►! Evening Telephone(_) -
Date of Accident/Injury or Date Discovered �C� u �yw�S.T/JL�Time J/: op /pm
?';casc �.(atc.iT� detail, v,�l�r��. occl�r:ed (h�}?pe�ied); anc �,:'����you are sub�nitting a cl���m. Please�r;nicate why or i����v✓ vo�l
feel the City of Saint Falil or its employees are involvuc� andior responsible Ior youi�damages. _ _
CN/'� e � Sr �,¢�/��.e I'!'�.�i� h.ta�.� /��.� �'���� �/�� �
i;���.s �.y f.rr u�,�ir ��u/f...�„w ti/� fi « �!�?` � ',�..r
��r � �5 .d-��A�.�r�—�•.�� n��tstt d,��a./S
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 pro erty
�Other type of property damage—please specify ��i� �� �/�� e� �sr.vsrrs.�/ 11��,
❑ Other type of injury—please specify
In order to process your claim you need to 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
O 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-please complete this section
Were there witnesses to the incident? Yes No Unlrnown (circle)
Provide their names, addresses and telephone numbers. � ' / i Ij►.�C
- > s �- �3�.�..� / a/� /.t S' . �i ' / f✓ E / s.
�,,, s .
VVere the police oi-law enforce�nent�led? � es �� 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. If necessary, attach a diagram.liSs //�.�irQ�.S.
��v'e`f,{tu , f�ttilA�d�[ O�SilO/�irlw�d _ d s �l-
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. /�-„�.,.�„�- ���,Q �/(���3 S8. `73
Vehicle Claims-please complete this section ❑ check box if this section does not apply
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__ _ � � � �
Iiijury Claims-please complete this section ❑ check box if this section does not apply
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�.
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 �-��' /Z
� Print the Name of the Person who Completed this Form: f UCG / � /J I� .ZJ�/�J 2 L��
I -� Signature of Person Making the Claim: �
Revised February 2011 �j9�� ��� 2 ��.
�
April 16, 2012
City Clerk
City of St. Paul
15 West Kelfogg Blvd
310 City Hall
St. Paul, MN 55102
RE: Notice of Claim Form Submission
Dear Sir/Madam:
This letter is to provide supplemental information to the Notice of Claim Form, filed concurrently.
On February 14, 2012, we received a call from our tenant, Bleach Hair Salon, located at 655 Snelling
Avenue South, alerting us to the fact that there was water coming into the building in the basement of
their space.
We dispatched our maintenance company,The Crew,to investigate the problem and determine a
course of action to remedy the situation. Upon arrival,The Crew notified us that they investigated and
there was no apparent leak from the building's water system, but there were two locations in the Bleach
Salon space basement where water was coming into the building.
We immediately called to the City of St. Paul and notified them of the problem. The City logged the
report and sent representative from St. Paul Regional Water Services to the location to investigate.
Over the balance of February 14 and then again on February 15, 2012,the representatives from St. Paul
Regional Water investigated the potential cause of the water leak. They checked various water lines,
listening for water running, etc., shut off values to see if they could identify the cause and other
measures.
All during this time,we had to hire crews to try and keep up with water removal so it would not
infiltrate into the entire basement of the building, covering approximately 8,000 s.f. this included a
truck for water extraction, pumps and constant working of a wet vac. We did have water into the next
space, but prevented it from seeping any further.
Finally, on February 15, 2012, St. Paul Regional Water Services decided to drill holes in the road (at the
intersection of Snelling Ave and Scheffer) above a water line they believed was the cause. Upon drilling
the second such hole, water and sediment came shooting out of the hole. This happened again on the
next two holes. Over the course of the next 40-60 minutes, the water subsided from the holes and the
water leaking into the building ceased.
It was determined that there was a leak/break in a City Water Main in the road,directly adjacent to the
corner of our building where the water was coming in. That line was repaired on February 16, 2012.
Once the water had stopped coming into the basement of our building, we were able to remove all of
the carpet and tile in the two basement areas impacted.
We have included the invoice for the work to remove the water, carpet and tile and all damaged
furniture and materials. The total for that work was$5,812.73. In addition, we have included the next
proposal for work in the area. This includes removing the paint that was damaged on the walls(letting
the walls dry), investigation of the walls integrity and what may have been damaged due to this incident
and the replacement of the carpet and tiles damaged. The cost of this work is$6,046.00 (a copy of the
estimate of the work is also attached). The total for the work identified above is$11,858.73.
In addition, there could be additional costs if the investigation of the wall reveals that there is additional
damage to the wall and foundation, as a result of this incident.
We have filed the Notice of Claim Form that was left for us by the representative from St. Paul Regional
Water Services, along with the invoices for the work completed and for the work to be completed, as
well as some photos of the water in the space.
We would like this matter resolved as soon as possible so we can recover our costs and bring the spaces
back to their condition prior to this incident. I can be reached at(612) 578-3615 if there are any
questions. You quick response is appreciated.
Thank you
/�-/ .
MASTNI N 2, LLC
Paul Tucci, Manager
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INVOICE
Bill To: Mastnian Z, LLC. Date Invoice #
c/o Paul Tucci February 29, 2012 12-07-100-01
1831 Summit Ave.
St. Paul, MN. P.O. Number Terms
Net 15
Job: 651 Snelling Ave. S. - Water Damage
Description: Emergency - Water Infiltration Clean Up Quantity Rate Amount
Emergency Clean
2/14/12 Report of Water Infiltration
2/14/12 On Site to Assess damage, C[ean Up, and Pump
W ate r
Project Manager 2:OOpm-3:30pm 1.5 $ 68.00 $ 102.00
Project Manager 3:30pm - 7:OOpm Overtime 3.5 $ 102.00 $ 357.00 ,
i
2/15/12 On Site ta Maintain`c�peratic�n c�f Pumps and C��an �I
up damaged items.
Project Manager 3:OOam -5:OOam Overtime 2 $ 102.00 $ 204.00
Project Manager 8:OOam - 11:OOam 3 $ 68.00 $ 204.00
Project Manager 12:30pm -3:30pm 3 $ 68.00 $ 204.00
Project Manager 3:30pm -4:OOpm Overtime 0.5 $ 102.00 $ 51.00
Emergency Clean - Pump Water and Clean/Bleach $ 4,071.09
Dumpster 1 $ 360.00 $ 360.00
Material $ 259.64
INVOICE TOTAL $ 5,812.73
Thank vou for vour business!
4839 West 124th Street • Savage, MN 55378 ph: 952..224..7609 • fx: 612..926..8548
www . thecrewmn . com
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March 23, 2012
Paul Tucci
651 Snelling Ave. S.
St.Paul,MN.
Subject: Water Damage-Repair
Dear Paul:
Thank you for the opportunity to provide pricing for the investigative work to help determine if there is any damage to your
foundation wall as a result of the water infiltration.Prior to performing the tests we will want the masonry to be dry, which will
require the PainUSealer be removed from the wall to assist in allowing the moisture to escape.Following the tests,the report will give
us direction in any repair work needed or recommendations.In addition I have included the price to replace the floori�g that was
damaged during this event.Please let me know if you have any questions,thank you!
Scope of Work:
Item 1—PainbSealer Removal $596.00
• Remove existing Paint from foundation wall such that the masonry can dry.
• Infill holes where water was entering with epoxy filler
Item 2—Investigate Water Damage within Masonry $1,050.00
• Perform Moisture Tests of Masonry to help identify if there has been any damage.
• Generate report of findings from data received from tests
Item 3—Flooring $4,400.00
• Replace VCT flooring and base that was damaged/removed during the water damage
Total Cost - $6,046.00
Thank you for the opportunity to provide you with this proposal. If you have any questions or concerns with the above information,
please contact me at 952-224-7609.
Sincerely,
The Crew Facility Maintenance,Inc.
Jeff Berends
President
(This Proposal is valid for 30 days)
ACCEPTANCE OF PROPOSAL: Price and specifications are satisfactory and are hereby accepted. You are hereby authorized to do
the work as specified. Work will be invoiced at the completion of the job. Payments will be made within 15 days of receipt of
invoice.
Client Title Date
4839 W. 124`h St Savage,MN. 55378 ph/24 hr: 612..816..1805 • fx: 612..926..8548
www . thecrewmn . com
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