Kaszynski .
NOTIC� UF �L������ �o th� �ity of�amt Fau�, l�Ii����
�� � Minnesota State Stutute 4�S6.Q5 states thut ";..svery person...wfio clainrsdaFriages from any mu�t�l,palft3}:_ sha�l�ai+s�i ly°,����lhe'
� governing body of dhe municipu�:t�+within i$Q tl�s c�er�Yhe allege�l�loss or�n,�iety is d�,scov�re��nolt��,�1��plat�e,.
� circumstar�ces"th�reof,a�td tX�e amount d,�'comp�s�ttAt�vr��her�re�tgJ'd$i��i�-;Y ,t{ ,���
.r�� " ��f .�.� +w t:�'�Fe��+OP {��
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Ple�se:co#t�p�ete#l��s£orm.in fts entiraty by'�IearT�t'y�ir�g or�rinting�o�ur answer to�ae�qu�ti+�t►. ��i�re spae�e is
�. -, ` ueei�ed,,a}�ach�dditio�al,sheets �Iea��tote that youi;will not be�o�ttactEd by tele�ho�ne_�a clarify ans�vers,-�q.�rp��ds as.
_much informa�iq��s,necessa,ry to e��a�'Youx;cla�ms aat�.t�e awbunf af comp�ns�#ao�heing.request�edr,Ynu�,viiU�'ece�ve a
wi�itten ac�now�c►i�g��e�t ogee your t't►rm is treceived. The pxucess�aii take np to:ten�i!��ks ar longer depend�ng.on the'
n�fare o€��ur cla�mi.'�'�#nrm�ra�tb�_sig�ed;an��r�thp�ges:c+��►ple#e�d. I������g d�s aot aPP�Ys'�`ri#e.rN�A'. `
SEiVD;CQMP�;E�'E� �`C3�NI�����D+Q���N�'S ��:`-��'�`�G�ER.�,
15 WEST k'E�I:O�$LY�,31� ���'Y H�:�;S.�I�I'ALTI�,MN 5�14.Z
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Fi�st Name ' Middle In2tial�Last I�i�e�_ . ��� k '
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Cc�mp�iy or Busii�ess l�iame.
Are"You at�.Insurance Compa7ny? Yes Na If Yes,:Ctairn Nurnber?
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S�eet,�d�Z' ss
City � 'Stat� Z�p�t�de�;�
Daytime Phone`(��,�� Phone,(��_� E�vening Teleptione( ) -
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Date of Accidetit/InjurY or Dat�Disca�vered �f•7�/i�. Time. •.� ,prri
. � ' = .i + ' _ .
Please state, in detail, what occurred(happened),and why you are submitting a cl�im.Please indicate u+hy or how you
fe 1 the Ci f Sain�Paul or it e ployees.are i olved and/or res onsi e.,�o yo r dama�es.
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Pl ase chec the box es) a ost c ose y r.epresent t re son for completing t form:
❑My v�hicle was damaged in an accide�t = ;' . �N1y.vehi,cle�vas c�mag�d d�ring,a;tdw
L7 NIy vehicle was damaged by a pi�tlial�or eo�dition of the;street > . �1�Iy vehlcl�:was da�mag�cl by a p1Q�uv
�� ' y veliicle was wrongfully towed aridlor ticketec�' ' � I was injur�tl"ori�ity property
ther type of property damage please specify O!
C7�O��t'�e of iiz�ury--please��pecify �' �` �
�..1 } y� k V.S il
ln order tci process your�larm vou neetl to ii�clutle:�obi�s of all�apulicable:d`ocu�ments. !
For the ciaims types liste�below,pl�ase�sur�to incY�ide�hhe ci��uments in�cafi�d�r it will�eiay the h�nriling of
your ciaim. Documents WILL N4T be retunned and bec�me�he}�ri�pe�o�tlie���;:'3�`ou are�enc,oui�ged tb'i�eep a
copy for you�self befs�r�;sub�niiting yQUr�laim forin. � :' - . �
O Froperty dariiag�e,ciaitt�s t�a v�hi�Ie:tv�v es�imates far the�epa�rs to yo�ur v�le if the damage�exceeds ` �
$500.00;or Lhe ac�ual b�11s a�d/or receYpts.for fhe repaars ' '
�;Towirig c�ai�ris:legi�ile°�opies af any ticket issued and a copy af tlie irnpoun�1ot receipt ` ;
�+ O!Other property damage claims:two repair estimates if the damage exceeds$500.00, or the actual bills i
and/oi receipts for the iepairs;:detailed list of damaged'items �
C) in,�uzy��clairns; metli�al�ills�receipts � � � �� � � ��� i
C�Pl�otographs are�Iways welcome to docum�nt 2nd support your claim but wi�l not be refurtsed.
Page 1 of 2—Please complete and return both pages of Claim Form ,
Failure to complete.and:re�arn both pages will resuit in de1a�in the handiing af your cl�im: �
Clainas— 'lesse coin lete this section ti`
Were ther�witn:esses to.t�e incic�e�t? .: Xes : I�o UnknQVCm (ci�c18) .
Frovi s th it naine `ad �sses d t�l ne n � �ers: ! ,
�; � � '"o ' .
Were th�palice or avv�er�oree n�lie�#? � Yes ' a ouvn` a�cle ! ���
c ) �.A,. . -�
I�yes,�¢h�t.clepartment or agency?. � � Case#k or r�port# � �.. �
� � � � � �_ � � �: ��.
Where dad the accid�nt or injur�take p1�.ce? Provide street addres's,cross street, i�teisecti�on;narne o patk�or acility�,�" !�
closest lan etc, eas�be as de ' as ossible. eee ,a h a.c3ia�ram.
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Please indicate the amount yo are seelan �in coinp a�i n or.w t�QU.w uld;like the City to do r�olve tlus clairn
to your satisfaction. _ � � ,:�� R ` , ` . .. : ,
��
Velucle Cl — "� ���
_ a�ims nl,�ase comnlete fhis s�chon - 17��ieck bpx�f thxs se�tion does not annlv
Your Velucle: Year Make Model
- �ic�nsse PI-a�e' �Tuml��r �. State Co��r -
I�egiStered�v�ner"
Ariver.a�'Uehicle �
; Area Dam�,ged
Ciry Vehieie: Year 1Vlatce ,I�Ilodel
License Plate Number State Colar
:Driver of Uehiel�(Ci�Employee's Name)
_ Area Damag�d , : ,
.: : : : � � . ; , .
In'ur Claims— lease com lete this seetio ❑ check box if this section does not a 1
How were you injured? _
VVhat part(s)o�your body`were injured? ,
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Have you sought medical treatr�ent? ' Yes No , Rlanning to.Seele Treatmerit,(eircle) �• �
When did you receive treatmez�t? (provide date(s))
�Name of;Medicai P�ov�ic�er(s):�_
Addz-ess ` Telephone
Did you miss work as a result of your inj Yes . No `:
When did�ou miss work?' ' (provzde,da#e(s)�
Name of your Employer:
_ Adc1r ss _ 1: _ , _, _ .� ��_ _ _ _� - - - , ;
.. � — �'�epho�� — - -� �- -,.; -
- Check here if you are attachmg�more pages to,this claim form. Number o�'additional pages,. '
By signing this form,you are stati�cg,t�iat ald information you have providetl is fru�and cprrect to the best .
o,f your knowledg� Unsigned',for�ns w�l'`not�ie processed ;
Submitting a false elai�n ea�resu�`�in p�osecution. Date form was com e#ed . �� ✓�
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Print the Name of the Person who Comgleted this Form: �h1Jl� ��'�'L�E.. �;.
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Signature of Person Making the Claim: C�. s� '
Itevised February 2011
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j " iNVOicE #: 3 2� 5 6 - �I
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� ' 1 DATE: � � Z o � � ST#: / I S S 3 �
� , CUSTOMER NAME(Financially Responsible Party) CALLER NAME lOB CONTAR NAME
� �/�/,l/Y� �Gic.,�,%';: '
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JOB ADDRESS CITY STATE ZIP
�' Since 1918 �� _ �,
i )�(- �_��;r< <� ,S�* � ,, iy,�/ S;�o�'
640 Grand Avenue BILLING ADDRE55(If Different) � PH7 PH2
St. Paul, MN 55105
� 651-228-9200
i E-MAIL ADDRESS •��
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www.mspplumbing.com .
I ORIGINAL REASON FOR THE CALL: 4 ' r �
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SUMMARY: � .. _ -� •� ��. „c .s i �
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See Summary of Fndings sheet
i � �for additional information
WORK AUTHORIZATION: i,the undersigned,am owner/authorized representativeltenant of the premises at which the work above is being dowe.I hereby authwize you to -y�,
perform the above recommendation,and to use such labor and materials as you deem advisable.Unless prior-authorization for billing,payment for all work done is due upon
completion(C.O.D.).A 510.00 BILLING CHARGE is due thereaftec An o�ce billing charge andlor finance charge of 1.75%per month(21%per annum)will be added after 10 days
past due.I agree to pay reasonable attomey's fees,court cosu and colledion fees in the event of legal aRion.I have read this contred,induding the terms and conditions on the �aX ' .
reverse side hereof and agree to be bound by all the terms contained herein.All old parts will be removed from premises and discarded,unless otherwise specified herein. �' `- '
I HEREBY AUTHORIZE YOU � .�� �
TO PROCEED WITH THEABOVE �� ' �.�;� _ � -� °��. ��
WORK AT THE UPFRONT FEE OF S� %'`�Y Signature:.'� ��� � '� ��"�
Qty Task# Description Rate
� Service Call Charge � �� ��'��
Service Partner Membership
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DISCOUNT ��.��J
❑Pre-Approved Financing Terms: ❑Please pay from this invoice-Work performed C.O.D. SUBTOTAL ���� .��-
PAYMENT 1 Cash ❑ Chec Check#: � � � � T�
MC ❑ Visa ❑ Disc ❑ AmEx Auth#: Nl�r S�vice Tectmician prese�ted me wi�a Service
Card#: Exp: m m ���+'«Jrarri and es�tained the benefig TOTAL COST `�� G�
Initial ONE
PAYMENT 2 Cash ❑ Check ❑ Check#: 1 want t�save money and ���� , , � � �
MC ❑ Visa❑ Disc ❑ AmEx ❑ Auth#: ��a��'re PartnFr
Card#: Exp:
m m At this ti m t decline the offer �-��'-� �
ACCEPTANCE OF WORK PERFORMED:I acknowledge satisfactory completion of SERVICE TECHNICIAN ACKNOWLEDGEMENT CUSTOMER SERVICE IS OUR#1 FOCUS
the above described work and that the premises has been left in satisfadory condition.I Prior to the customer entering into the contract,I have
understand that if my check does not dear,I am liable for the check and any charges from the discussed the nature of the service and cost and I have �f you are not completely satisfied for
bank.I agree to pay 1 JS%per month for past due contracts(minimum charge S15).In the given a copy of the con4red to the customer. All work I any reaso s �H a d a to speak I
event that colledion efforts are initiated against me,I shall pay for all assaiated fees at the have done has been in compliance with company With the` ���e Serv anager. j
posted rates as well as all cost of collection fees and reasonable attomey fees.I agree that the standards i�a wo manship manner,to building codes
Your f a ry impo #to us. i�
� amount set forth in the space marked"TOTAL COST'is the total flat price I have agreed to. when applicable. � � ;�a��,
SIGNA l '�-; :�' �� -� � ' � � SIGNATURE � ' '���"-""'—- -�ANK Y SING US FOR
YOUR SERVICE NEEDS!
� I dedine to have the recommended work at this time. SIGNATURE DATE O Copyright 2004 Nezs[ar"'.All Rights Reserved.
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„ - serwce require4 fa�.nore than just a teci>nidan, toots and parts p,<<±i€y3p�ice rnvol.�s wt3s#antial
invcstment o, ��°�,, • . �=y al..i:r.�;, -,��r;�. Ur. .�� ,e, �:cinq a vc�i�lc'e, we f»i�st�ftdve(to your.dO�r
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�,r;, �,-c�ives tr�„� . �<�fe<�� v;�erl<.�s the*ec, „�,;tan�trrtve:i , E _�:_= c-�are some o#ithe�te!z?s�vhici,
COCIV 1 ,.. ;C;�1(?C'1"f;:, y��f:. - ' � .,. . �-aa , . ..
Iliet¢�uw.w�i�y ` . _ � . .
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� � , ��� '.c�> , �.,<..<<f� ; re�ay c�fls:o the n�arPSt ser.„� '<�� . . ��?^ � s�:?sthed�?e s2ot�s for
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VVe w�fu,d axzur�uate r,�ar�r,q lron;toar ir y<>�. �,-v�a�., �a.��zbiems n+ sr�c7c�F,irr�ns.
�nem`>er AIr'y�yi*�-�R. `f,...>,riJtOtl?�r) .1.�4.;c. , .. .�,r:�t�t
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, � .. . , , TERIVIS At�D _ m� -�
Ct3NDIT10fV� - ,;�'�"��,��
RESPONS#BILITIES OF Ci?��s�PJ(ER: � � � �
�UStOFil2( t'2pi'2S@Y1tS ts�.d� � �.,' <.d,�.- _.>. - , i.rltS' �, .. , , ?�ti'Tii.;; .— .. ..�i 7 i:t3t .,_�, � , + �';1!!;51/5?l'f115 dCE I[l
t. _ � u 3 _ . . . , ,
gOOC'� fB(J81(dilC�COf'J ` _ . . - _. ... _ ." '�_'. , ��i"sl� 5 '�t?l� i�3c ->Ct1t:ry �?�f.a� 'c'.t,,�< ., sC�iiti7,b, �nC'. ,� � tj t?i., t,1. [!it _'c'�tU thC fO��OWillg:
, ,
t. Impro�>er�r fautty��t ���i;iny �t �,r�es:�h�� .,e settied c�;broke:n 7. Improperiy ci�arged systerr,s 1fl. irrip;�oper orfae�ity eiectricaf �
2. Ruste: or defective pi�es 5. Exi�tinc� il�ec;�i c:>t?ciitions 8. Faulty air moven�ent 11_ Irriproper voltage by pov��er
3. ;�: ! .. <<�E ,'�<,,r7 ��,stc�r7� ,. �� `z�tiv. r,�.f,ng 9 � :�c. �' :'.�"�r7� cc�� ;parly
RESPONS{BILITIES OF SELIFR:
Sel;er sF,al! do aIl work ;;�, _ .� ���pE.r,�� -:.� rxt��anii��e��nariner �ei�� i5 ;c�r���or7sii�le for any existiny iliegaf to^d;tions.
LIMITED VUARRANt�':
Company warrants its work ta be#ree fram defects in materiai and workmanship for the warranty period af ninety(90)days from cempletion
uniess othervvise stated in writing or,the��ce r?ereof. AI!drair st��ppac,�es are v�✓�rranted �er� peried of ihirty(30)days from the�_ornpletion unless
otherwise stated ir��vritir�j ;;n,th�c f�ce i�ereof_,�li vtsarral�ties ar�, uoid if p��,r,ent;s no; r.� �!� ,�he�?caue_ UVa�rant+es extend oniy io�the customer
and are not transfera6ie. if a defe�t in materials or worki��ansf�i�c�vered by tF;�vvarrairty o�� ;rs, S�;ier wili,witn re�sonab(e promptness dur:ing
normal Uvorking l�ours, re�r,ecly t��e defect. Ir, no everi'shal'i Sel[er F�z !-e��i "�a���t. �[vr t ,:t�;�r� oi��e�� �.�roage caused by any delay in remedying a
defect. To obtain vvarran:y�erformance, noti#y Seller af any defett or daim for breaci�at the a�idr�ess and telephone number on the face hereo€.
EXClU5ION5 and lIM{TA710N5:
CUSTOMER'S RIGHT?O REPAiR AND REPLACEMENT a,KE CUSTOMEft EXCLU�illE RECr(:i�lES.SEiLER S� °� ��OT �E LIAE3LE FCft ;NCID[NTA�OR
CONSfQUENTIAL DAMAGES.
Sel(er is not responsible for the foilowing tivhich are exduded from the coverage o�this lirriited warranty:
1. Detective conciitions iis:ed under the abovE °Responsibilities of Customer."
Z. Work performed t�y o� �n�Eerials i��stailed "by�others r�ot ir, ihis aq�eer�7enf. �
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- 4: -#oid devefopment or moM detectian-of any kind. __ _. ;_.___.:. _._. �_. __.
"THE LI�l1iTE:D UVARRAN i Y ST,^-tiTED r=�BOVE i5 i�HE ONLY WARRr�N;Y SELIER MaKES. SELLER (4'IAICtS NO WAr2ftANTY OF iV1ERCNANTABILITY OR
FITNE55 FOR A FARTICULAR PURPGSE �0�; :C;�,� SOi C, OR ANY i�THEft l�'✓RRRAN�1�; EXPRE55 QF, i"-�iPL.IEl�."
PROrECTION OF CUSTOMER`5 PROPERTY:
Customer agrees#c ren�ove or protect�ny{�ersonal property, inside and out, inc`u:-�� ,�; t3�at nc�t li^7;ted tn carpets, rugs,shrirb�and oiantir�g,;and�
. _.
Se(ler sha�i not b: r�a�����:; zr�i�for said items. Nor shail SelJet be�ield res�onsibte E� ,s,e ��atural cc�r_seqUences cf Se�(E r's vvcrk�°b�hich ii�ay cause
damage to irnproveilier;�.��.;f��,� property induding, but not limited to,curbs, vdev�aiks, �J�!ks, r�ri:�eways, c3�rages, p�ti;>s,lawns,shrubs, sprinkler
s�,s±e�;,s, ;nraii�;aper �;yw��a'!, st��cco, tile, cabinets and other appurtenances to thE� rt s J�r,ce c�r�rr.�i pr;�oe�ty.
S�eFler sh�i�not be helti respansibfe fot c;�mage to aersor.al property, reaf proper�;�c�r any i�7� ��:�emew?ts t� rea! pr�perty caused by p�rsons
�ieliveri�},Y'nateriais or equipment, o�kee�ir�� gates and doors dosed for ch�idre, � .:,�;����n�i<,
�-�1RE AGREEMENT: �
"'fh�is is tfi�e 2ntire agreemen+'�The`��rt=.es�re:�ot bound bp�any aral expresson c--e��r:ent.ation by any agent purporting to act on their behalf,
or by an�corr;mitment, or arrarge�*�er�t izr�_;���T��agr���=;ient bi�jds;c;r;t'� «.��� s . .�,'y a`I ��-r�ing as Customer, their heirs, repr�sentatioris, �
s�ic�ess.��� ���c,' a>>�grs 5;��E r �sii: 7c>t ��rovide an �'errized breakdowrt c�f r,.,��ri��;s u ,�. `:abc.r.
WARRANTIES,AND LIMITATIONS OF WARRAN71E5:
Nc srarrant;�, exoressed ar implieci, is proviiied l�or ar��y existing systerrr�or applia:��ces.A+iy aiterations, arlditions or.�pa�srs�made blr others unless
autherize� c3r agreed upon by SelEc . ��:+�i L .s� ;o term �,ate Seiier's ob;:qation ;;i�dc:r ih�s contract
Nexs!ar'�;z�n ascxra!icn oY irrde e��dern.sen , ��•�<,> >,�r?i�a ron;r tc, . ����h:.� , �;�-;� �.�,,u.r. � ,�..•. ., ::_;, , �e„� ._ . ���:r.r,<�> , `c:�. n ��,f;>r, e„rc,r,al s�ruiurd::
p _.. ,. .
and pr'aride suN.�-or�z�zw��r� ser 1,�,q��-ast.,-:;not an owner of i2s membe�'s busiaesres and each men.6cr's� siness u r���epe�ciantty o�vned and oc�rate�.Conseq_�entty,tVexstar makes no
warranties or re�reserrtation;tAat tt i�,���R,�e,scrrbed ht �in�+vilf he perfio;med iit accortY�n<e with.Jrxstdr�n <s..�.,.�:x!standa�ds.
�
� If you nofice a leak or loss of
; water, please call 651-266-6874
24 hours a day, 7 days a week
Hu rau SPRWS qhov chaw txais tos pab qhua ntawm
651-266-6350 kom tau neeg pab.
Wac adeegga macamiisha SPR WS oo laga helo
651-266-6350 si oad u heshid kaalmo.
Comuniquese con el servicio de atencion a!cliente de
SPRWS a1651-266-6350 para obtener m6s informacidn.
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:�> ��.
1900 Rice Street
Saint Paul, MN 55113 �,',
� .
20 01 004 ^
Distribution Division
�": , . 1900 Rice St
,�:� • Saint Paul MN 55113
.._ `, °
, :.,.,,;,� -;:
`$ " Mark Luzinski
WATER SERVICE SUPERVISOR
Phone•651-266-6868
Cell Phone•651-775-3186
. Fax•651-266-6878 E-mail•mark.luzinski@ci.sipaul.mn.us
�
Karl Dodge
Master Plumber
► ' � 651-228-9200 office
651-228-9201 fa�c
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