Howie F��li�l��v
� �Ui� 1 2 2012
� NOTICE OF CLAIM FORM to the City �_�3�f��au1, Minnesota
Minnesota State Statute 466.05 states that"...every person...who claims damages from any municipality...shall cause to be presented to the
governing body of the municipality within I80 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."
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 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
I^ 1 �I ,
First Name . V�I�� Middle Initial !J Last Name TTVuJ�e-
Company or Business Name r� ��
Are You an Insurance Company? Yes No If Yes, Claim Number? � 1°-
Street Address �V��-- ��t �I�C� v N��
City �� �� State ��� Zip Code � �
Daytime Phone((�� ).��-�3y_Cell Phone((oS_l )3�-t3 -�'-L Evening Telephone( ) -
Date of Accident/Injury or Date Discovered I� lUn[4�. �01�- 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 f S 'nt P ul or its employees are involved and/or responsible for your damages.
� � �
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
❑J.VIy vehicle was wrongfully towed and/or tickete p , ❑ I was in ured on City property
�Other type of property damage—please specify�er�eV � c��ur� �� -S�a.u�� l�a� �M¢a� � e� µ�ECn�
❑ 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 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 PropeRy 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
�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
r
� Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims—please complete this secNon
Were there witnesses to the incident? es No Un o,�'n , (circle)
Provide their names, addresses and telephone numbers: �� (�Z�;c� /� � • �2 a�c;� c i.7�'Pr,.� • �u�- �5
�i� �a,M'�re2 . �-� ✓►1a�,�.rw �hc �(os� • `Il�, y3aa()
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. If necessary, attach a diagram. o�O�,Z ,�fi �/a,n �iu.�All.�
��'T_ltc�� �crw� �.� -���5�c�.i,u rt• t���c!'G�� ��
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Please indicate the amount you are seeking in compensation or what you would like the Cit to do to resolve this claim
to your satisfa tion. � 0 . � r
' c- -� - a
Vehicle Claims—please complete this section Ry,check box if this section does not annlv
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
Iniurv Claims—nlease complete this section '6lJ check box if this section does not avnlv
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 fornts will not be processed.
Submitting a false claim can result in prosecution. Date form was completed �� l� ��
Print the Name of the Person who Completed this orm• ►�-+ � �
Signature of Person Making the Claim:
Revised February 2011
, Howie—2092 St. Clair Avenue Attachment#1
Summary of Claim
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.
In May 2009, we had our water main replaced as part of a larger sewer line project at our home(2092 St
C/air AvenueJ. Due to a number of re/ated issues/incidents that occurred during the execution of the
water main replacement(coordinated by Al Czaia, Right of Way Inspector), a large hole was left beneath
our front steps(see Attachments 2,3, 4, &5J for a number of days. In addition, the hole was improperly
backfilled, which has caused the ground/sidewalk to settle an additiona/6 inches or so.
Through conversations with vendors in March 2012 regarding repairing these steps, we were advised
that these factors—the lack of support represented by the hole underneath our stairs for days, combined
with the ground settling due to improper backfilling—have resulted in an acce/erated deterioration of
our front stairs. While the stairs were not new at the time of the original incident in May 2009, they
were structurally sound and were expected to/ast another 8-10 years. As seen in Attachment 6, our
stairs are now quite literally falling apart due to these circumstances and require replacement many
years earlier than if both the ho/e and improper backfilling had not contributed to the accelerated
deterioration.
As St. Paul Regional Water Services was determined to be responsible for the portion of the hole that
extended well beneath our steps, a/ong with the improper backfilling of this hole that resulted in further
settling/deterioration of the support for our steps, we feel the city(St. Paul Regional Water ServicesJ is
responsible for the cost to replace these stairs and are asking for compensation to that
effect. Attachments 9,10, & 11 to this claim form are bids received for replacemenc of these steps from 3
local vendors.
Attachment Detail
Attachment#1 (this page)—Summary of Claim and Attachment Detail
Attachment#2—Stair/Hole Photo 1 (May 2009)
Attachment#3—Stair/Hole Photo 2 (May 2009)
Attachment#4—Stair/Hole Photo 3 (May 2009)
Attachment#5—Stair/Hole Photo 4(May 2009) i
Attachment#6—Stair Photo 1(May 2012) I
Attachment#7—Stair Photo 2 (May 2012)
Attachment#8—Stair Photo 3 (May 2012)
Attachment#9—Repair Bid from E-Z Masonry Inc ($2,900 for stair replacement)
Attachment#10—Repair Bid from Armstrong Concrete Inc ($3,735 for stair replacement)
Attachment#11—Repair Bid from Vogel Concrete ($4,985 for stair replacement)
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1535 Grand Avenue• SG Paui, MN 55105• 651 917-9329 (Phone) • 651 917-2195 (Fax)
�.�a��Y� MN BLDG Co�tracta Lic#BC627703
PROPOSAL# 12343 SUBMITTED TO OWNER: WORK TO BE PERFORMED AT
Add�: 2092 St dair Ave
Katie Howie sa�nt Paui MN 55105
2092 St Gair Ave -- _
aint Paul MN 55105 Phone#s: Home: 651 470-2748 work:
cdi: bsi 4�o-z�4s
We hereby propose to furnish all the materials and perform all of the labor necessary for the completion of the fdlowing:
Item#: 1 Remove&Replace Grade Steps
Removing and replacing the conaete grade steps with poured borders situated at the public walk leadirig up to the front lawn.New steps
shall have 9 unifortn risers and measure approx 4 ft wide with 8 in wide bwders.Concrete shall be a minimum 5.5 in tt►idc,4000 psi with 1
#3 rebar every 16 in o.c.ea.Way. Indudes resef.ting the existiny handrail on cmnpletion,
Item Price: $2,900.00
Item#: 2 Remove Sc R�lace Front Sic�walk
Removal and replacemerrt�the concreGe sidewalk extending from the aforementioned steps to the frorrt entry stoop.New sidewalk shall _
measure approx. 12 fi long and 4 ft wide with a smaller section meawri�g approx.7 it long and 2.5 ft wide.Indudes demdition,base
preparation,forming,pouring,and finishing of new concrebe,ConQete shall be a minimum of 3.5 in tf�ick,4000 psi Placed on a minimum 2 in
of damp,rnmpacted granular base.*The price listed bebw h�been disoounted and assum�acceptance of Item# i in this proposaf.
Item Price: $700.00
Item#: 3 Remove&Replace Errtry St�oop
Removing and replaang the concrete stoop on new concrete{rost footing at the froM entry to the house. Includes demdition and disposal of
the existing above grade concrete. New stoop sha11 have 3 uniform risers and measure approx.6 ft wide with an expanded 3 ft landing to
meet city code. Conaete shall be a minimum 5.5 in thidc,4000 psi.with 1#3 rebar every 16 in o.c.ea.Way.Prices indud�installation of
two iron hand rails similar to the existing rail at the grade steps and Gty of St Paul�ilding pennit*The price Gsted beloyv has been
discounted and assumes acceptance of all items in this proposal. A la Carte acceptance of i�dividual items may impact the list price.
Item Price: $2,750.00
_ _ ___ -s__..,_._ ,.____�_.__.._..___.._...__�_ . _._._.. ___
. -_._ _...
All material is guararrteed to be as specified,and the above work to be performed in accordance with tfie drawings and/or specifications
submitted for above work and completed in a substantial workmaMike manner for the sum of: �6,350.00
with payment to be made as fdlows: 30%upon acceptance and net due on satisfactory completion.
• Any alteration or deviation from the above specifications involving extre costs,will be executed only upon written orders,and wil�become an extra
charge over and above the estimate. AII agreements are contlngent upon accidents,weather and other acts of God or delays beyond our contrd. �
Owner is responsible for fire,tornado,and other necessary insurance upon above work. Workman's compensation and Public Liabillty Insurance
on above work to be taken out by E-Z Masonry,Inc �
Respectfully Submitted on 3/22/2012 by Kevin Ramirez �'"
� �
NOTE-This prop�al may be witfidrawn by us if not accepted witfiin 10 days.
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The above prices,specfications and conditions are hereby accepted. E-Z Masonry inc.is authorized to do the work_ Payment will be made
as outlined.I have read the attached general specification and understand the information detailed within,induding the pre-lien notice.
Signature(s) Date
Page 1 of 1
t�o�`�e � ��ti � � � — ��
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RMSTRON �-
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� CONCRETE ING. ` ��
5485 Pineview Ln N, Plymouth MN 55442 • Office:612-703`-2004 • Fax:763-�55�-�62$ _+'_ �
www.armstrongconcrete.com
Minnesota License Number. 20375998 _
Estimate prepared for• „ „ � �
Name t'�d�i� t"1 I,,�� Day Phone � � �– �`�_l� �,��� �
Address ����_ �.�, �� ��_��� Eve Phone �
?� f r1 u.1 /��l �� l 2� � Faac/Cell
Proposal
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Specifications
Mix Design: ❑Exposed Aggregate; 4,000 psi,air entrained concrete with " river rocks
�Broom finish (exterior); 4,500 psi, air entrained concrete �
❑Smooth Finish (interior); 4,500 psi, air entrained concrete
Reinforcements: �Steel rebar ❑Steel wire mesh ❑Micro poly fibers �
Thickness: `�4" ❑6° ❑'Ot}ier ' '�
,� _ _
Coating: 1�(Matte curing and sealing compound �High gloss curing and sealing compound � ; ._ =�
Concrete work is covered by a Five Year Warrant�. For warranty details and terms of s . � _ �
see back of contract. No landscaping is included in the estimate unless noted. ��� � �x
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NOTICE OF LIEN RIGHTS AS REQUIRED BY MINNESOTA LAW: , � � � �;
ANY PERSON OR COMPANY SUPPLYING LABOR OR MATERIALS FOR THIS IMPROVEMENT TO Y'L���$
PROPERTY MAY FILE A LIEN AGAINST YOUR PROPERTY IF THAT PERSON OR COMPANY IS NC�i��;,���C��.�f
THE CONTRIBUTIONS. UNDER MINNESOTA STATE LAW,YOU HAVE THE RIGHT TO PAY PERS��1�Y��'-
SUPPLIED LABOR OR MATERIALS FOR THIS IMPROVEMENT DIRECTLY AND DEDUCT THIS A�������� '
OUR CONTRACT PRICE, OR WITHHOLD THE AMOUNTS DUE FROM US UNTIL 120 DAYS AFT� � ���:'��
OF THE IMPROVEMENT UNLESS WE GIVE YOU A LIEN WAIVER SIGNED BY PERSONS WHO S� `�►�� '
LABOR OR MATERIALS FOR THE IMPROVEMENT AND WHO G YOU IME NOTICE. Initi ` � � �`
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.i' 3�n.:3 syk:
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Estimated by Date _���
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Total of Estimate Accepted by Date _ ,��:
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` Page No. �..� of Pages
�p N C R E rF 65 3��40 PROPOSAL
yQGE� Fax: 651-714-2128
C�HST R U CT��N 1854 East Fifth Street
St. Paul, Minnesota 55119 WE RECYCLE �
MN Lic#20635515
PROPOSAI SUBMITTED TO PHONE DATE
ST�E,�, -P �-}�,�� -F' �s l� y�o � �?y� 3 .�ad � 1 �
JOB NAME
ao�a S-� . C�a�lL— .S-F��S - S r rr��w� 1 lc
CITY,STAT D ZIP CODE JOB LOCATION
c•J 1'�'('C�W( �V�w �
ARCHITECT DATE OF PLANS JOB PHONE
We hereby submit specifications and estimates for:
n AMOUNT
I�ew•a�{ °� �,s.�2_ �.�,�� �-�� � c�.,�� 11 ' o�' i��,�+ �„a:l �..
�a,�� a,`� �f �3�t 5 ��6Lo-:.�. S ;�F_ / �n S��� �� /U�w �7 Q�sr f1�
��-f�� � ��-� s� �r �� i(s ��� y 'X �� ' d �' �<�Pw� ��
/���YI�Y!q(/�Yi^ � (` � I�lt G IL � C (�c. /� /'� P I Dt TO C<<'f�sY Cd P/t C� P7'�'
E.S-�`�IXtI"f' 1 l��5 P� �k"' JC'.✓L S l 4 itl G�fit� �t�at T!eo ( �!�t�'l:�'S
� d �'v d'� �-.r �`�- i z'X'fY.��� � f
S � � CrldS`'� C�u� - Ovr {�
C�-(- c���.2 5`r�e. ��2 Q r r �►�'�'-� (1 ��u� �Q� I n c�� S , �``/;`��'S�P=-
� � � � � ��.�(�-�- 5-�l � �-�� ��0-4«S �,�.� 3� " r���f%�� _ �(�� °�
� TOTAL
DESGRI PTION MATERIALS __
�oD� �$f Co.� tR���
s��,(-�lZ.
G-l�.n.�� �
�x 7�h�,�,n
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We Propose ereby to furnish material and labor-complete in accordance with above specifications,for the sum of:
0
~ � �d � � � P /�� dollars($ ).
Payment to be made a toliows:
One year guarantee for materia�s and workmanship.No guarantee for cracks or heaving.
All material is guaranteed to be as specified.All work to be completed in a substan-
tial workmantike menner axording to spedfications submftted per standard prac- Authorized
tioes.Any atteration or deviation from above speciflcations invdving extra costs will Signature
be executed only upon written orders,and wfll become an e�tra charge over and
above the estimate.All agreements contingent upon strikes,;accidents or delays Note:This proposal may be
beyond our control.Owner to carry fire,tomado and other nece�sary insurance. w�thdrawn by us if not aCCepted within � days.
Acce�fance of Proposal-The aba�e p���,specifications
end condi ons are satisfactory and are hereby axepted.You are authorized to do
the work as specified.Payment will be made as outlined above.
Signature
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