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Reynolds - - P�GE �11'�:3 . � �PRW� E�3113/2012 a9:02 6512666378 ��id'�°..': �1AY � 7 r,-�;f �- ;1 • ' ' pistrif�ution Division ;, � � � 'f900 Rice Street �I i"��,4�;tt:�:_ � , . Salnt Paul MN 551'�3-681� ��X C�VER SH�ET �� Date: 3J1.3/2012 . --- mduding caver sheet} 3 Tota{ pages (' L�A�� DELIVER TO� Name: Maree Cook CompanylAddress: 1Vlenio Park Sfi Paul Fax: 651-G03-9aa9 F�onn: Liz Quickseli � Name: 651-2�s-6875 � Phone: 651-266-�fi878 Fax: E-maii: liz.quicksefl@ci.stpauf.m�►.u� Attached is a damage claim form that can be fi��ed�ut�n reference to the propertY at ].2�6 University Ave W. Please��{ it vut as completely as poss�b�e and includ�any documentatian (photographs, invoices�etc.)and mail ta the address on t1'►e fo►-m• P�ease let me know i�you ,I _ have any qu�stions.Thank you. i � G:\F�RMS\fsx._d?.stri�butzon.doc PG�E �J�'f 1�:3 �3113!^012 69:�2 651'�666878 SPRWS NO'I'��E UF �L,AjM �'O� to th� Cxxy o�Saint Paul, 1V��nesota F �--.. .Minn�sota StatP 5tatutN 9G (i_OS states thnf " ...evFry Persnn...who elainu oss ogz�ryxis du ofv�red ajreoiice sttcrtin�thE firri�e,rlace[a d r zr: ��verning hna!v of rlse municipultty wlt hix 1�0 d a y s a f t e r r l t e a t l s R e �ircumslances thereof and the amount of corr�pencation or ot F z�r re 1�T t e��qne�tion. if more space ic ciearl ty ►ng or printing yonr answ answers,so pro�ide as tele 6one ta c�$*►�Y Ftease complete this form in�b entircty bY y p in re uested. Yo�n'>>�reccive e needed,attach additivaa�shccts. Ple.ase note that yoa will not be contacteci by p er de ending on the nsatian be� g q to ex lsin your c�8�m+and the amount of cornpe t�ten weeks ox lon� P ntucl�inf.ormation as neccss9ry p rocess can tal:e np � vvrite`N!A'. written acl�no�ledgement once your f��s received. �'�e P nature of your clsim• Th�R F4rro must be signed,and both pages co7np�eted. if sanaething daes not apF Y± ANA UTHER DOCUMENTS TU: CITY �5 aR�� SEND CON�P�ETED FOR.N� �14 CIT�k1..A.LL� SAINT PA.UL,MN �5 WEST KELLU�G�3LV�� - � � G�� Middle initial��st N�me �irst Nam��.�---- – Company ot Business Name �� Are You an Insurance CompanY� �'�S��Y�s'�laim Nusnber? Street:�.ddxess i� ' J�5/4�� State /�/� 7ip G�de�._.—. Ci.ty � - Q�t �vening p �j paytime Phone(j��eeit Phone�)�---� le hone I I��„2 Time��" � �r" pate oP I•leci.dent/Injury or Date Discauered ;�_� �claim.Pl�ase indiaqtc why or hpw}Jou in detail what occurred(hagpen�d),and u'hy you ar�submitting Flease state, � Q feel he City o'�S��nt Paul�c its employe s are involve�dlc�r ScsPons��e fnt y°ur damages. . � Plea.se check tkte lx}x.(�s?that mvst closely represent tize reason for completittg��s form: ❑My vehicle was dama�ed dura�g�W�v p Tvly vehicie�vas damaged in sn accident ❑My vehicle Was dama�ed by p Q My vehicle was damaged by a pothole or condition of the street 0 I�,�injured on City pt�perty p Mp�vehicle was wrongfully to�"red and(or ticketed �her type�f property damage–pleasc speeify � her type of injury–pleas�spECi_fy In ordcr to proccss your claim ov need to include co ies of all a licable documents. - ' c i es listecl below,please be sure to include the docu�m�n� �he�City� Youla e�encoUra�ed C°ke p a Fc�r thc claun� yp your claim. Dc�cuments WI�._L N�T b�r��'`Ed ar.d beconr►e the 1�' P e exceeds copy for yoursetf beforE submitting yaur claim form. �y p�operty damage claims to a vehicle:t�wa estimates for the repairs to your vehicle if the amag $SOO.OQ;or the actuat bills and/oT recelptsc et�issued$snd thc c!a.maf e excceds$500.00c ax-�the�ct�'ai i�ills Q Towing claims:legibte copies of any �Other properf.Y damage cta�ms:tvvo repair estimatcs�f g ed items and/or rec�ipts for the repairs:detailed list of damag O Tnjury ciaims:medical bills,receipts Q Photographs are always we]come to documcnt and suppo�t yQUT claim but will not be returned• pa�e 1 of 2–Please conaplete a�nd return bot6 pa��of Claim For� P��E 03�0:' ' ' � SPP4�aS 0'3I13l2612 09:02 6512E55878 . nd retar�a kx'th P��vill result i�delay ia the b�andling o£your clainn�. Failut'e to comp�ete a ,p�,ll Claims- ��C°� ��te this sectiop� No [Jnknowtt � c�rcl�} Were there wifiesses to the incident? Y�5 Provide their names,addresses and telephone numbers- Yes �� Unknown (circle) Were the police nr la•�v ettfoxcement called7 Ca�� ar report# If yes,w'hat dcpartrnent or a�cncy7 ark o�facility, take place? Pravide strcet address>cross st�rect,intersection,name of p Where did the accident or injury eeessa ,attaeh a diagram. � clasest tandmark,etc. 1'lease be as det�iled as possible. If �3' � � u aTe s�eking in comp�n�tio�or�h�t Y�'u ti"'�uld like tha C:ity to da to resolse th►5 claim Please indiCa'Ce th�amnuntyo r, ��. � to yo«r satisfaction. � 'i . '- /� �r�t� _ j� h,� �?.� � � ;% „" c�v�'�i�+ f�-�r�.� "p�check bo�if t'his s�ti�n.does t a 1' <` �'o �vi � ,y �� o Vehicle Clainls- 1.��am I�te t ' section ��el � ��k� Color � Your�eliicle: Year�----- Sta.te �,,� _��,G 1,icense P1ate Number � � Registeted Owner �v�� Driver o�Vehicle �� ' \ Area Dannaged M�del e � C�ty Vehicle: Year�—Make . gtate_�CQlor ��l� License Platc Number Empioyee�s Name) r� Driver of Vehicte{City .� hrca T�amaged p check box if this section does not a 1 S In'u Claims- ae�se co� lete th"ss oecbon How were you injurcd? What part(s}of your body were injured? Nave you sought medical treatnnent? Yes No Pl�nning t�Seek T�atment(cir{pCQ�i�e�ate(s}) When did you receive treatment`? Name of Medical Providex(s}: Telephor�� Address No tprcvide date(s)) Did you miss work as a result of ti�ur�n1ury� Yes When did y�u miss work? Name of your.�mployer: Tclephon.e Address �._......: ❑ Check here if you are�ttaChit►g�ore pAges to t�xs claK��oz'�• Nu�ber of�dditi�na pa� - statiri that alt informahonYau have p�'ovided i.s true and correct to ihe best .8y s�g�i�zg this form,Yau are g o fy,��.k�wledge. Unsign�d forms will not be proressed. ubmittr.ng a false claim�an r¢sult in prnsecutin�. Date fo�waa completed S ^ - S C'or� /L��' - � ' P�ri�nt tbe N�me of the Pet'son wha Completed this Form: � �.�v�� .��,, Si��aatu�re a��e"'so°Mak'ng the Claim: Reviscd Fchrusry 2�>> ' 38371 ' Invoice No- Nasseff Mechanical Contractors �� 1 122 South Wabasha St. Ste. 101 �� Page St Paul, N1N 55107 M��p�y1Gp(, CpIIITRACTORS 777-0001 Phone: (651) . , . . � ' Fax: (6�1) 602-9296 B S MENLO PARK I I 12q( �1IVERSITY AVE L xEn�o�s exovp T K s5io� I, 1246 UNZVE�ITY AVE E ST PAUL 1�Il�1 ST PAUL IrR3 55107 T � Contract No. Pnt T�rms I�ivoiee Date Invoice�To. Customer No• PaY�" RAY002 NET 30 DAYS 04/26/12 38371 Unit Extended price Pnce U�t tion Qty Meas Descrip 1 . �`icket# � 40 �r _�t, ��1J1��.lrL C! !+ `f'D . „ O # - 820426003 J�o�'rnaC fG�� is � ' � �5� o Qc�"s w/ �j0 1��1 14 12 Brian Heutm�ker & Joe Dragich �¢ � Qu O 3/12/12 3/ / � � � Service Request: oke, no water to jrd & 4 Pressure booster p'umP seal br floors. Servi.ce Perfora►ed: arrival. Said 3�12�12 turned off already upon my �/� So� had p'�P here when on. Was told to ^ � 1• water everyw y p�p vras sPraYing , e fastest way to fix it• � ,�e replace p�P if it s � to find a replacement p�P �� 2, Called Goo�n & MulcahY p�so checked on a Gruncifos CR8-30 is a disofl�ead and order kit and have it seal kit, JoYui said to g overnighted. 3, Ordered kit. 3/14j12 d �rove to job site. I 1, picked up P�P Seal an assemblY also bad. Took pumP aPart and fou�d bearing 2' bearing assemb1Y. none in tO�' 3ohs� 3, Tried finding lained tlze situation. q, Talked to John �d exp approved t11e replaced of t�e entire p�P- 5 Ne� P�p to arrive next week. 6, Cleaned uP area. _ �apPed moto�' wires- � , Left p�P mostly apart 715.0 110.00 58� � 6 �� gg pIPEFITTER LA�OR 587 •76 55.0 820426003 i O� � p� g�I, RIT 55.fl� 1.00 EA TRIp CAARGE _ __ .., T u U E D Nasseff Mechanical Contractors Invoice No. 38371 122 South Wabasha St. Ste. 101 �� page 2 St Paul, MN 5 5107 MECHANICAL CONTRACTORS Phone: (651) 777-0001 - � • ' ' " Fax: (651) 602-9296 B I S rsExLO p�c �, REYNOLDS GROUP j I, 1246 UNIVERSITY AVE ,r 1246 UNIVERSITY AVE ST PAUL 2+IN 55107 E ST PAUL MN 55107 T O Invoice Date Invoice Na Customer No. Paymen�Tezms Contract No. 04/26/12 38371 RP,Y002 NET 30 DAYS Unit Unit Extended Meas Descri tion Price Price Ticket# Qty P I TO PAY BY CREDIT CARD, C,O TO nasseff.com AND CLICEC �r�NLI�,. pp,yMENT" AT THE BOTTOM OF TFiE HOME PAGE. Past. due invoices may be subject to a finance charge of 1.5� per month (18� annually) . y7E AppRECIATE YOUR BUSINESS! Gross Tax et Amount _ ___ .00 1,357 .76 Nasseff Mechanical Contractors Invoice No. 38372 122 South Wabasha St. Ste. 1 a l �� St Paul, MN 55107 Page 1 MECHAili1CAL GONTRACTORS Phone: (651) 777-0001 ' � ' = ' ' ` Fax: (651) 602-9296 B I S j, REYNOLDS GROIIP � MENLO PARK j_, 1246 UNIVERSITY AVE .I, 1246 UNIVERSITY AVE ST PAUL IrIl�T 55107 E ST PAUL 2�i 55107 T O Invoice Date Invoice No. Customer No. �'ayment Terms Contract No. 04/26/12 38372 RAY002 NET 30 DAYS U�� U�t E�tended Ticket# Qty Meas Description Priee Price W/O # - B20426004 3/21/12 Joe Dragich & Pat Greiner Service Requested: Replace Grundfos booster pump. �� Service Performed: � 1. Picked up pump from shop. 2. Drove to job and started replacing pump. c�� 3. Got new pump in and motor wired. �' 4. Had to re-pipe bypass iine. �� 5. Turned on pump to check rotation. 6. Manager asked to leave off and in bypass. They will turn on when city is done working on water in the street. 7 . Found a couple af leaks on existing piping when we turned water back on. 8. Manager gave us the go ahead to make the repairs, will return. B20426004 12.50 HR PIPEFITTER LABOR 110 .00 1,375.00 1.00 EA BOOSTER PLJMP 2580 .18 2,580.18 TO PAY BY CREDIT CARD, GO TO nasseff.com AND CLICK '�pNLINE PAYMENT" AT TAE BOTTOM OF THE HOME PAGE. Past due invoices may be subject to a finance charge of 1.5� per month (18� annually) . WE APPRECIATE YOUR BUSINESS! I Gross Tax Net Amount i '� _955_18 .00 3,955.18 � Nasseff Mechanical Contractors Invoice No. 383�3 122 South Wabasha St. Ste. 101 St Paul, MN 55107 �S�FF Page 1 NtECHANlCA! CONTRACTORS , , . , , , . Phone: (6�1) 777-OOQl � Fax: (651) 602-9296 B I L REYNOLDS GROUP s MENLO PARK L 1246 UNIVERSITy p�VE I 1246 UNIVERSITY AVE S T PAUL I�i 5 510 7 T ST PAUL I�1 5 510 7 T E O Invoice Date Invoice No. Customer l�,TO.g Payment Terms Contract No. 04/26/12 38373 RAY002 NET 30 DAYS Unit Unit Extended Ticket# Qiy Meas Description Price Price W/O # - B20426005 _ _ _ 3/23/12 3/26/12 Joe Dragich Service Requested: Repair leaks found on existing piping: � Service Perforsaed: �,/ 1. Cut pipe and unbolted flange. ' 2. Repaired leak on 2" male adapter. S? 3. Put back in with slip coupler but valves didn�t hold and couldnTt solder it. � 4. Got approvai to shut water off to building on Monday. � 5. Shut off water and draine�i build.ing. 6. Soldered fitting. 7. Turned water on and cheeked for leaks, norze. 8. Systera is operating correctly at this time. � i R B20426005 5.00 HR PIPEFITTER LABOR 110.00 550.00 � 1.00 EA COUPL/SOLDER 32. 00 32.00 ( � � # TO PAY BY CREDIT CARD, Gp TO nasseff.com AND CLICR � "ONLINE PAYMENT" AT THE BOTTOM OF THE HOME PAGE. E � Past due invoices may be subject to a finance , � charge of 1.5$ per month (18� annually) . � WE APPRECIATE YOUR BUSINESS! i , i � � Gross Tax Net Amount � 582.00 . 00 582.00 ,