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Boshey RECElVEa ���:;����i�a�� ___ _ JU�I 1 8 2012 �UN 1 � , .. -�, NOTICE OF C��i�C�'�M to the City of Saint�Paul, 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 municipaliry 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." I Please complete this form in its entirety by clearly typing or printing your answer to each question. lf more space is needed,attach additional sheets. Please note that you may or may not be contacted by telephone to discuss your claim i circumstaaces,so provide as much information as necessary to explain your claim,and the amount of compensation being requested. This form mnst 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 �('f c�,t��. Middle Initial� Last Name �U� Company or Business Name,if applicable Street Address ��l.� l�i,� �vr���'rz. City �:��r�� ���\ State 1''�N Zip Code r�5li�� Daytime Telephone (�''2 )S'l� - b'16"L Evening Telephone( t,a tZ) Sq�l-e�l�;,. Date of Accidentl Injury or Date Discovered �''1�y� �����— Time �3� am pm circle) Please state,in detail, what occurred, 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. A ^�2.�� �S �:.2.�n� 'u��bt���cc� �2.C2�.:.`:�2 , �� 't.h42. t_�^-tl� hcv�eJ2>r�� �n ficl� Of ll(o � 11V�.Mc�, .\ � k r,- < ��...�,c_ � �.i,r� . � � - ; � ^n .. �6 <. ,c1 �� � -s o� ' , � c,r h /'� � ' ��I-Q,wi��c- an�1 �f�n. �a. c�kv cf �.:•:act o,�o'► �5 I�av.�.� k,aca�.:� �� �s ��, c:�t��s -tr� �.n�� �rx:��1 �._Lrlrlr2S�,1 isetore. rU�.�. b�c�ic. _ �mm�rr.rntSUla��a ��v'�_ cl�,r��-fn -i�l�./c�r��•t,o:�rvrsO�c4a�,T �hiiln �5 (lctt �2.�t crE ►:�r' r�V ctf�41... h r�tAwr��! —r —�— Piease check the box(es)that most closely represent the reason for completing this form: ❑ Vehicle was damaged in an accident ❑ Vehicle was damaged during a tow ❑ Vehicle was damaged by a pothole or condition of the street ❑ Vehicle was damaged by a plow ❑ Vehicle was wrongfully towed andlor ticketed ❑ Injured on City property �Other type of property damage—please specify rE��c�n�C�r� or����m��g. ❑ Other type of injury—please specify ❑ Other type not listed—please specify In order to process your claim you need to include copies of all anplicable documents. This is a genzral guideline of what shoul�' be submitted with a claim form,but it is not all inclusive. You may be asked to provide additional information depending on your claim. O Property damage claims to a vehicle: at least two estimates for the repairs to your vehicle,or the . actual bills and/or receipts for the repairs O Towing claims: legible copies of any tickets issued and copies of the impound lot receipts • Other property damage: repair estimates, detailed list of damaged items O Injury claims: medical bills,receipts � Photographs can be provided but wil.l not be returned. Page 1 of 2—Please complete and return both pages of Claim Form ' Failure to provide a completed claim form will result in delays in processing. Notice of Claim Form, City of Saint Paul,page two All Claims—please comnlete this section � Were there witnesses to the incident? Yes No Unknown (circle) If,yes,please provide eir names, addresses and tele phone numbers: n� -�db �e.' bar us.;n !�i��rt (S�- av�- 7SG, 9r�. �a �Ke S�c:wf q.�� � sid Were the police or law enforcement called? Yes No Unknown (circle) Tf yes, what department or agency?��, 7eeL. �����ll�<l 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 helpful, attach a diagram. �11a C.a��e. Au�r�� ��,In�,�-,t c<^`� �ir rt �., �{ ��+c . 1 Please indicate the amount you are seeking in compensation from this claim or what you would like the City to do to resolve this claim to your satisfaction. �h,2t�% �0 �r l r�m� �«4� �-t�MP U���In ��u�u.t i-ru�- C�a�M Cfl,�n1�l;�x�\D��sSl�' clr 1 S �� t�S ItCs - SlC�ln�, oFLti�aa� ' Vehicle Claims—please complete this section �check box if this section does not applv i� Your Vehicle: Year Make Model � License Plate Number State Color �' Registered Owner I Driver of Vehicle � Area Damaged City Vehicle: Year Make Model License Plate Number State Color Driver of Vehicle (City Employee's Name) Area Damaged Iniury Claims—please complete this section �check box if this section does not applv 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 i �Check here if you are attaching more pages to this claim form. Number of additionai page�. 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 elaim ean result in proseeution. 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V Pollock Construction LLC 2846 Brockman Court Northfield, MN 55057 (612) 366-2674 Bree Bushey & Victoria Dibble 916 Case Avenue St. Paul, MN 55106 763-639-3980 Bushey Porch Roof Replacement 5/29/2012 Description Quantity Unit • BUILDING PERMIT (AVERAGE AMOUNT FOR 1 PER U.S.): JOB Building permit fee, based on total amount of job • DOWNSPOUTS: 24 LF Remove downspouts from building • GUTTERS: 31 LF Remove edge hung gutters from building • PORCH ROOF: 1 EA �I Tear off entire roof structure over porch, up to 240 �' SF, leaving only platfarm, posts, and railings • EXTERIOR WALL COVERING: 108 SF Remove siding from existing exterior wall Aluminum or steel siding removal • WOOD BEAM: 31 LF Wood beam bearing on existing supports, beam either solid or built-up, pressure treated lumber two 2" x 12" • BAND: 77 LF Western red cedar 1° x 12" band • TRUSS ROOF: 103 SF Gable roof trusses o Shop built by others and delivered to job o Placed by hand o Tie down straps o Includes 2 gable ends 24" OC Truss roof, 2" x 4" chords, 24" OC • PLYWOOD: 128 SF Oriented strand board 1/2" OSB sheathing • ASPHALT OR FIBERGLASS SHINGLES, 260 LB. 166 SF (25 YR.): 260 Ib. roof shingles 4 to 6 in 12 pitch II • ALUMINUM SOFFIT: 31 LF Ribbed soffit, including "F" channel Aluminum soffit 12" • ALUMINUM FASCIA OR RAKE: 31 LF Fascia or rake trim Aluminum fascia 6" • HOUSE WRAP: 108 SF Substitute house wrap for paper specified in siding installations • ALUMINUM SIDING: 108 SF o .024° thick horizontal aluminum siding o #15 felt paper o All accessories, including starter strip,J- channel, utility or undersill trim, one piece inside and outside corner post o Not included are soffit,fascia, rake and window and door trim Aluminum vertical board & batten • GUTTERS AND DOWNSPOUTS: 55 LF Gutters and downspouts, including accessories LF=Total combined gutter and downspout length 5" seamless aluminum gutter • PORCH CEILING: 103 SF Fir beaded ceiling, center beaded one side and center V-joint other side 5/8" x 4" porch ceiling • FASCIA OR RAKE: 77 LF Up to 12" fascia or rake with brush, one face and edge Paint fascia or rake, Prime and 1 coat I • PORCH CEILING: 103 SF Paint wood porch ceiling with brush Paint porch ceiling Prime and 1 coat • Provide a 10 yard dumpster for construction waste 1 EA removal. Project Total: $5,017.36 1�.�L WE'Ll GET THE JOB DONE RIGHT! BBB T FAMILY OWNED AND OPERATED • FULLY INSURED HOME 763-421-4841 CELL 763-218-2666 CUSTO EAM SS GUTTERS 11924 PENNSYLVANIA AVENUE NORTH•CHAMPLIN�MINNESOTA•55316 Owner Jason Hoskins www.custom-seamlessgutters.com Date � � � �`� Home N�� Cell ��0�����—��b� Lifetime Warranty on Labor and Material. Name �'��' ��`� �5'��` MATERIAL LIST / r Address ���"� ��� '�`"� ?� � GUTTER 5u�h}' �uu�� /�N �71 J� �` FLASHING , �� 2 X 3 DOWNSPOUT BACK OF HOUSE � 3 X 4 DOWNSPOUT CORNERS 2 X 3 EXTENSION ' 3 X 4 EXTENSION `�"'��`�=- GUTTER COLOR DOWNSPOUT COLOR � � f--`+ � SCREEN GUT"TERS j ��� �. FRONT OF HOUSE SCREENS T^ TOTAL � ��f �� SPECIAL INSTRUCTIONS SIGNED ACCEPTANCE OF THIS ESTIMATE&PROPOSAL CONSTITUTES A BONA FIDE SALES ORDER AND AUTHORIZES DELIVERY & PE ORMANCE TO BE COMMENCED. THE CUSTOMER ACKNOWLEDGES THE fERMS & CONDITIONS. C.�v�' CUSTO ,-SEAMLESS GUTTERS CUSTOMER APPROVAL AND ACCEPTANCE �- � . � '�•�r3 `°d_ . � .. � ••i , t. �,, _ � �- ;,