Schultz RECEI�fEG
MAY 0 3 2012
NOTICE OF CLAIM FORM to the City of Saint P��,����sota
Minnesota State Statute 466.05 states thaf"...every person...who claims damages from any municipality...shall cause to be presenfed to the
governing body of the municipality within I80 days after the alteged loss or injury is discovered a notice stating the time,place,and
circumstances thereof,and the amount of compensation 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 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 reyuested. 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. Ifsomething 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 ���n;+ef' Middle initial � Last Name c�c�►u�f Z-
Company or Business Name kl�,
Are You an Insurance Company? Yes No If Yes, Claim Number?
Street Address l�9a� �or��rc�z � � ` ,
Clty �� ��/ State IYl iU Zip Code �SS//(�
Daytime Phone(�l )�- ��/v Cell Phone(�5'/: )aN6- 676� Evening Telephone (',S/ yya- 73a7
Date af Accidenb Injury or Date Discovered I}�G��� �6��7 av�Z Time 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 andlor responsible for your damages.
S'�e �z��l,rr,� le�e�
Piease check the box(es)that most closely represent the reason far cornpleting 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 0 I was inj�?red on City property
P� Other type of property damage-please specify >,�ki{-e� �n
❑ Other type of injury-please specify
In order to process your claim vou 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 WII,L 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 far 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; ar the actual bills
and/or receipts for the repairs;detailed list of damaged items
O Injury claims: rnedical 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 Unknown (circle)
Provide their names,addresses and telephone numbers: ��- �-�-�t C��a Y!'I�.-�;►-,
�sy- ��-�y�� �ri- 7.s.�=.�.�6�
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 facility,
closest landmark,etc. Please be as detailed as possible. If necessary,attach a diagram. S,-� ��� �
��7�� Y�6/�T/Pa � HV� ��/�.��, /�7/V ���(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. ��a 39.5z� s�c c�-F�u c�.�d
Vehicle Claims–please complete this section �check box if this section does not applv
Your Vehicle: Year Make Model
License Plate Number State Color
Registered Owner
Driver of Vehicle
Area Damaged
City Vehicle: Year Make Model
I.icense Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Iniur,y Claims–please cQmplete this section l�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 6ere if you are attachiug more pages to this claim form. Number of additional pages�.
Gnd u p{r�+o G'�
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: Jeh n i�� � �� 1�Z-
Signature of Person Making the Claim:
Revised February 2011
Shortly after we purchased our house at 1992 Montreal Ave in 2007 we started having problems
with our main backing up into our house. At that time I called the city and was told that it was
our responsibility to repair the problem. We called out a plumber and had the pipe snaked and
cleaned out. After doing this a few times over the last few years we came to March 26th. I was
doing laundry when I noticed that the water was starting to back up again. I placed a call to
Roto Rooter to come out and clear the line. After spending a few hours trying to unclog our main
it was decided that we should put a camera in the drain to see what exactly the issue was. In
doing so we found an abnormality in our pipe. The next day, March 27th Roto Rooter came
back out and tried to "Jet" the pipe (please contact Roto Rooter with questions regarding what
this process entails), but this did not work. It was decided that the best course of action was
to dig up the pipe and and see what what going on. They could not tell if the pipe was broken
or if there was a foreign object blocking the line. On Wednesday March 28th Roto Rooter
started digging in the median of our street to get to the pipe. When they reached the pipe it was
discovered that part of the pipe was broken. There was an empty space surrounding the pipe
that should have been filled in with grout but because this wasn't done, the area surrounding
the pipe filled up with water, causing the pipe to move and break. Roto Rooter then called the
city inspectors to come out and take a look. That is when the city told Roto Rooter to put a
temporary fix on the pipe, saying that it was done incorrectly and that the city will be back out
in the near future to re-do the temporary fix with a permanent one. The pipe in question was
installed incorrectly in 1996 as part of permit R-101979.
A few days later I received a phone call from a city worker letting me know that I did not have to
worry about the bill from Roto Rooter from March 26th-28th because the city was going to pay it
directly without my involvement.
I am submitting this claim for the past bills from the plumbers that had to come out and snake
out our main thinking that it was our fault and for the 2 days of work I missed on March 27th and
28th when dealing with this problem at home. Attached you will find copies of those bills, contact '
information for Roto Rooter and the city of St. Paul, photos from the broken pipe, a history of
sewer plans we received from the city, along with a letter from my employer stating that I had to
miss work to deal with this problem. I am not asking for you to pay for any damages to my home �
or clean up costs,just simply the money I had to pay out to fix the problems we faced because
of the improper repair made to our main in 1996.
Thank you for your time with this matter,
Jennifer Schultz :
1992 Montreal Ave
St. Paul, MN 55116
651-246-6762 �i
_ Itemised Compensation
_
__ _
_ _
'Date Explanation Amount .
3/22/2011 Plumbing bill from Professional Drain Services $179.00
, _ _ _ _.
5/14/2011 'Plumbing bill from Professional Drain Services $243.50
_
`Plumbing bill from Minneapolis Saint Paul
1/5/2012'Plumbing $175.00
_ _ _
1/5/2012 Plumbing bill from Roto-Rooter $362.00
3/28/2012 Time missing from work . $280.00
_ _ _
_
Total _ $1,239.50
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Roto-Raoter Seruice Company
Remlttance Address� '�
5672 Collectlons Center Dri�e
Chlcapo IL 60693
ST PAUL BRRNCH
For Ser�ice 1 800 GET ROTO i
For Bililnd (651) 638999A ,_
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Thursday. January A5, 2612 �`�? '
In�otce #22fi 16520053 �>E '
Tech; ADEYEYE #22fi-1211 -
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JENNY SCHULTZ � '
1992 t10NTREAL AUE � ' , �i
SRINT PAUL, tlH 551162009 '
1200 I1AIN SEWER STOPPAGE CLERR FROM �273.00
CLEAN OUT TO t1AIN-SIHGLE REEL
RECOt1t1END CAt1ERA =�a
SERUICE Gl1ARANTEE; 6 t10NTNS
981A ADDITIONAL CABLE REEL ON JOB �139.08- �==g
SERUICE GUARANTEE: 6 MONTHS r
UEB SITE COUPON $50.00CR �;
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TOTAL SERUICE AND PARTS $362.00 ;;� •
TAX 90.00 �
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.•. l'OTRL �362.00 �
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Account� XX)Q(XXXXJ(XKX8382
RUTH#t 095563362fi -
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ROTO ROOTER PLUt1BERS �
I RCKHOWLEDGE WORK DESCRIBEU RBOUE WRS DONE TO
MY C0IIPLETE SA7ISFACTION AND RUTHORI�E PAYMENT.
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------------------------------------------
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ignature Date �: . `
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----------------------�------------------
Print Name � I
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Apri120, 2012
To Whom It May Concern:
Jennifer Schultz needed to take March 27 and 28 off from work to deal with water problems at her
home. It has been determined that the City of Saint Paul was responsible for these problems. Jennifer's
lost compensation for the two days she was not at work totals $280.00.
Kelly Pelzer, Manager
IFO MS UNLIMITED INC
935 N. Dale Street
Saint Paul, MN 55103
i
l
i
2220 Lyndale Avenue South 935 North Dale Street
Minneapolis,MN 55405 St.Paul,MN 55103
Phone:612-377-0011 Phone:651-224-7567
Fax:612-377-0406 Fax:651-224-0766
Tol I-Free:800-328-9202 Toll-Free:800-328-9201
� �/� �
RO�V' °"�'� CHAD MARTIN
ROOTER• S�'W01 Solution Specialist
PLUMtIM6� �;s/- 7SS-33G g
011��M SERYICE .
�•soo-cer-ROro S�n•�ce
�a_;x-,hxr,i
(65�)G3x-9990 Phonc
Roto-Rooter Scr��iccs Company ��51)ti3R-9997 f�ax
99 Sth Avenue Northwest �
Suitc 200
New Brighton,MN�51 12
����w.rotorootcr.com
BILI. AWKER � -
Sa°�+�rr Utilitv
... ,..!,�; -��� /.� ��/_.(,. / /�l% .
_ �
CITY OF SAINT PAUL
DEPARTh1ENT OP Pl�[3LIC WORKS
700 Cin Hall An��r.r
W� ?�lk'est Four�h Snrci Ti�l. (GSI)266-6?-11
Sainr Paid,MN_SSlO.' h'u.c':(liSlJ 298-SG?1
e-ntail:bilLni+k�v(dci.stpnttl.mn.tr.s
Hrspo�r.virt•Sa•rrirrs•Qunlil�'Facilitie.c•F.ntpluyee Pride
.V�G.� ��, � (,c:_ �;'�'(�� /, `-' =`r f
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/ '
;mail - Fwd: Sewer permit records https://mail.google.comlmail/u/0/?ui=2&ik=e2147869d2�cview=pt�ias...
. � °
—�—.-----
� Jennifer Schultz<schultz.jenniferj@gmail.com>
a� � �
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Fwd: Sewer permit records
Jake <mry'schultz@gmail.com> Wed, May 18, 2011 at 1:39 PM
To: Jenny Schultz<jrai11983@aol.com>
---------- Forwarded message ----------
From: Lori Lemke <Lori.LemkeCa�ci.stpaul.mn.us>
Date: Wed, May 18, 2011 at 1:26 PM
Subject: Sewer permit records
To: mr�chultz�a pma, il.com
Jacob,
Permit A-58565 is a permit for a paving connection that was installed in 1930 from the sanitary
main to the property line. Paving connections were installed as homes were built for future hook ups
to the sanitary main. When your home was built in 1946, permit A-67386 was issued when they ran
the sewer pipe from your house to the paving connection. Permit R-101979 shows that you have new
6" ductile iron pipe installed in 1996 from the main back towards your house 29'. The ductile iron pipe
should be
fine and puts you near your property line. I see that there are 2 very large trees on either side of your
sewer service. That is probably your problem. Tree roots getting in the joints of your old clay sewer pipe
from the house to the property line. Old clay sewer services consist of 2' sections of pipe that were
mortared
together. Over the years, the ground shifts and the mortar disintegrates, leaving open joints between
sections
of pipe for tree roots to get in.
Take a look at our website: www.stpaul.gov/sewer "
Once in the home page, select "Property Owner Information" on the left side of the screen.
Lots of good information, plus an award winning video to watch regarding private sewer services.
Lori Lemke
City of St. Paul
Public Works/Sewer Utility
Office: 651-266-6230
Fax: 651-298-5621
Email: lori.lemke@ci.stpaul.mn.us
4 attachments
Montreal sewer print.pdf
� OK
l of2 1/5/2012 12:05 PM
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