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NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
Minnesota State Statute 466.05 states that "...every person...who claims damages from any»2unicipality...shall cause to be presented to the
governing body of t/ie municipality within 180 days after the alleged loss or injury is discovered a notice stati�ig the tinae,place, and
circumstances thereof, arid t/ie a�nount of compensation or other relief denianded."
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 PAiJL, MN 55102
First Name v��Q��' Z� Middle Initial�Last Name /'�n� m...-,�,P-�•.�
,� ,
Company or Business Name
U
Are You an Insurance Company? Yes No If Yes, Claim Number? � ,
Street Address �� ���.�I��l.r�U r ����(,����
City ��, ���L State��/ Zip Code-<y��
Daytime Phone (�)���Cell Phone (��-��Evening Telephone U -
Date of Accident/Injury or Date Discovered ��-�����_Time�_am/�
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.
I�---�—�
/
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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 or�City propei-t�,�
�Other type of property damage-please specify ���/�L�/ � �1 �� l A�,�L '� �`/���C D
❑ Othcr typc 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
�Other properly 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
�hotographs 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
__
_ _ _ �„
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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:
Were the police or law enforcement called? Yes ` No Unlrnown (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 poss 1 If nece sary, attach a diagram.
����C.���,A/�/�
Please indicate the amount�ou are seeking in�compensation or what you would like the City to do to resolve this claimL
to your satisfaction. �
� , � � — ���—
— �ehicie Claims�lea�o�p� I�te�t�'nts sectio ������ ❑ check bux ii tiiis section uoes��ot aapiy
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
Iniury Claims=please com�lete 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(eircle)
When did you receive treatment? (provide date(s))
Naine 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 sig�zing this form,you are stating tlaat all informatio�z you have provided is true and correct to the best
of your knowledge. Unsig�Zed for�ns will�iot be processed.
Submitting a false claim ca�x result in prosecution. Date form was completed '-' ��O �' ��
Print the Name of the Person who Completed this Form: ���P���.�� ����
Signature of Person Making the Claim:
Revised February 201 1
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679 CHEROKEE CLAIM
o On August 1 St, 2012 the City of St. Paul began work on the sidewalk on the
Morton St. side of our property 679 Cherokee Ave. During that process they
unnecessarily tore down a very large portion of our retaining wall that was
adjacent to the sidewalk and also severely damaged the retaining wall extending
into the conjoining alley (see diagram/before and after pictures).
o We were not given any prior notice of any kind that the City of St. Paul intended
to destroy our private property or that they had any concerns what so ever of the
stability and/or condition of the existing retaining wa11.
o If there were any concern on the part of the City of St. Paul that the retaining wa11
could fall or that it was "encroaching"on the sidewalk,the work needing to be
done to the adjacent sidewalk could have been postponed until we were given
proper notification, even cited if necessary and then the issue could have been
addressed at that time. Instead the City of St. Paul made the decision to damage
our private property and to send the only notice of any kind concerning the
retaining wall the day after the incident occurred. (see attached letter)
o The retaining wall adjacent to the sidewalk was not encroaching on the sidewalk
in a manner that made it unsafe or impassable for pedestrians. (refer to pictures
#6 and#7). It was stable. It was not a public safety issue. If it was, why weren't
we notified previously when the city has been out to patch/repair cracks in the
sidewalks or when the crew came around and marked the sidewalks for
replacement? When the streets were repaved or swept?? The City of St. Paul has
been out for multiple reasons on previous occasions and the reta.ining wall was
never cited.
o The retaining wall that extended into the conjoining a11ey was also stable and
undamaged prior to the removal by the City of St. Paul of the retaining wall that
was adjacent to the sidewalk. (refer to pictures#3, #4 and#5)
o The City of St. Paul could have applied other methods to remove the sidewalk
that would have not done any private property damage to our retaining wall
however they choose not to do so. The old sidewalk could have been"scored"
prior to the removal,thus eliminating any need to remove the retaining wall along
this portion.
o There could have been much more care and delicacy applied to this job; however
everything indicates that it was done hastily and without any concern for
attempting to use any other methods other then what was the quickest; thus
causing our retaining wall adjacent to the sidewalk to be needlessly torn down and
our retaining wall going up the alley to be damaged as well. No concern or extra
attention was given to preserving our private property what so ever.
o We would appreciate your help with processing this claim ASAP to insure that
further private property damage does not occur due to the fact that the earth wall
that is now exposed because of the retaining wall being torn down is now unsta.ble
and could fall onto the sidewalk at any time.
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DEPARTMENT OF PUBLIC WORKS
Rich Lallier,Director
CITY OF SAINT PAUL Dan Haak, Manager Telephone: 651-266-6080
Christopher B. Coleman, Mayor Street Engineering/Construction Fax: 651-292-6315
� 900 City Hall Annex
. � 25 W.Fourth Street
' Saint Paul, MN 55102-1660
�
The Mosc Livabia
Ciry In America
August 2, 2012
Joshua Aydt
679 Cherokee Avenue
Saint Paul, MN 55107
RE: Property at 679 Cherokee Avenue. PIN: 072822320116
Dear Mr. Aydt:
On August 1, 2012 the City of Saint Paul started performing sidewalk replacement on West Morton Street
between Delaware Avenue and Cherokee Avenue. The work being performed is to replace the city sidewalk, as
needed, to ensure a safe pedestrian passage along that street for citizens.
While removing the existing sidewalk along the Morton Street side of your property, the retaining wall from
your property fell over. The reason for the collapse appears to be the fact that the retaining wall has been
pushing out over the years and had encroached over the city sidewalk.
Since the retaining wall encroached onto the city sidewalk, responsibility for any repair to the wall rests with
the property owner. The contractor will be removing any remaining parts of the retaining wall that interfere
with the replacement of the sidewalk.
If you have any further questions, please feel free to contact me either by phone 651-266-6108, or by mail at:
Allan Czaia
City of Saint Paul
Public Works
900 CHA
25 W. 4TH St.
Saint Paul, Minnesota 55112
Sincerely,
��L.L�� J a� -
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Allan Czaia
Sidewalk Supervisor
�Qapsive S�ryc
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'"�� An A�rmative Action Egual Opportunity Employer Q. s�,N� 4
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� PROPOSAL
` 7471 Lamar Ave. S.
Cottage Grove, MN 55016
Owner: Ernest Nelson Jr.
��. Office: 651-769-9131
Fax: 651-493-3245
I ' I I ' ' I ' � I ernestconstruction@comcast.net
MN LICENSE#20468148
Proposal Submitted to Phone Date
Street Phone
City,State,Zip Job Location
We hereby submit specifcations for:
Method of Payment:
❑Visa/MC
';�1 Cash/check
'� Discount $
WE PROPOSE hereby to furnish materials and labor, complete in accordance with the above specifications, for the sum of:
dollars ($ ).
All Material is guaranteed to be as specified. All work to be completed in a workmanlike manner according to standard practices. Alterations or
deviations from above specifications which become obviously necessary during construction, may result in extra charges not to exceed 20% of the
contract;any other changes which result in extra charges will be executed only upon written change orders.All agreements contingent upon strikes,
accidents or delays beyond our control. Owners to carry fire, tornado and other necessary insurance. Our workers are fully covered by Workman
Compensation Insurance.
4-year workmanship guarantee.
PRE-LEIN NOTICE AND ACKNOWLEDGMENT
Upon acceptance of this Proposal,this document becomes the Contract and Agreement between the parties,and
under Minnesota State Law you are hereby further notified as follows:
Any person or company supplying labor or materials for this improvement to your property may file a lien
against your property if that person or company is not paid for the contributions.
Under Minnesota law,you have the right to pay persons who supplied labor or materials for this improvement
directly and deduct this amount from our contact price,or withhold the amounts due them from us until 120 days
after completion of the improvement unless we give you a lien waiver signed by persons who supplied any labor
or material for the improvement and who gave you timely notice.
Note:This Proposal may be withdrawn ACCEPTANCE OF PROPOSAL-The above prices,specifi-
if not accepted within 30 days cations and conditions are satisfactory and are hereby
accepted.You are authorized to do the work as speci-
ERNEST CONSTRUCTION fied.Payment will be made as outlined above.
Signature Date
By:
Authorized Signature Signature Date
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