Ferstenou NOTICE OF CLAIM FORM to the City of SainR�a�u�, �innesota
Minnesota State Statute 466.05 states that "...every person...who claims damages from arry munic�.�hgll���s to be presented to the
governing body of the municipality within 180 days after the alleged loss or injury is discovered a notice stat:ng�time,place,arrd
; circumstances thereof,and the amount of compensation or other relief
E�Tt°`���c�t�
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 ezplain 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
First Name (��/ ,���t M�ddle Initial- L. La.st Name��R S"�i�0 t�
Company or Business Name �, .•
Are You an Insurance Company? Yes/� If Yes,Claim Number?
Street Address �q�5 S�'!C r i�a h���.t�±U P-
City��. �Q u � State_� /�/ Zip Code 5 S!/(�,
Daytime Phone s� ���� Cell Phone�)�- 2(e76 Evening Telephone(_��s�e- ceG(>
Date of Accidenb Injury or Date Discovered l 2�28 ��ofX� Time `$ �a� �/pm
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 andlor responsible for your damages.
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w� �1�f+B.eQS AT Iq3't sH�t2.�D,l�l _ .
Please check the box(es)that most closely represent the reason for completing this form:
0 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 on City property
81 Other type of property damage—please specify SG—�►Ca2 RE P��)2
❑ Other type of injury—please specify
In order to process your claim vou need to include copies of all analicable 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 WII.,L 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
O Other properiy damage claims:two repaii 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
Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims—ulease comulete this section _
Were there witnesses to the incident? Yes No Unknown (circle) �/�
Provide their names,addresses and telephone numbers:
Were the police or law enforcement called? Yes No 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 par1 or facility,
closest landmark,etc. Please be as detailed as possible. If necessary, attach a diagram.
Please indicate the amount you are seeking in compensation or what you would like the City to do to resolve this claim
to your satisfaction. 'rHE" S/I�rn� t.G—�(rcL OF ��?'►PENS/�'T�ol�[ �oK wl�f-1C.1� A� _��OkJUEa2
Wovt�p R��vE FaR- A-Si r��LA� .�tt.s�T�h-T�oN . iN T+{E G�E � o��e..
rt6t6N�3oR r �•��t s�t�a�w�,l, THE e�TY �� �tc6EV�r iN6 R�s�a��B����rY, -
. Vehicle Claims-please complete this section _ �.check box if this section does not aunlv
Your Vehicle: Year Make Model
License Plate Number State Color
Registered Owner �
Driver of Vehicle
Area Damaged
City Vehicle: Year Make Model
License Plate N�mber State Color
Driver of Vehicle(City Employee's Name) �
Area Damaged
Injury Claims—please complete this sectiqn �check box if this section does not apply
How were you injured? � . . � � . .
Wfiat part(s)of your body were injured? ' . � � , . , .
Have you sought medical treatment? � Yes No ' Planning to Seek Treatmerit Ccircle) � •
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
ojyour knowledge. Unsigned forms will not be processed
Submitting a false claim can result in prosecution. Date form was completed Q�3a�.'t�jt 2
Print the Name of the Person who Completed this Form: �N��L �E�.S�-�(nU
Signature of Person Making the Claim: C�-����_
Revised February 2011 �
Webster Com an Inc. Invoice
py� Invo�ce Number:
845 Edgerton Street 18842
P.O. Box 17124
St. Paul, MN 55117-Q124 Invoice Date:
Voice:���i}�76-2733 Jan 31, 2001
Fax:(651)778-8815 Page:
1
Date, Description of Work, & Jobsite:
Sold To: Dan Ferstenou Dec. 28,2000 & 1/4-5-8,2001
1935 Sheridan Avenue Repair sanitary sewer
St. Paul, MN 55116 1935 Sheridan Ave.
St. Paul, MN
_�
Customer ID Customer PO Pa ment Terms �
1924 � Net 30 Days �
—
Quantity i_ Item ( Description ! Unit Price Extension __
; �Install sewer clean out on existing sanitary sewer in � � ;
� boulevard for sewer cleaning.
Break out frost&pavement in the street at the existing
drilt hole location. Repair as needed. Place temporary �
istreet patch. ;
'We found a junction box installed on the drill hole for i
other sewer connections. The connection from across the �
street had broken. I
It washed out under the junction box and plugged the drill
hole forcing his sewage to back up into your house.
1.00 2001 ; City of St. Paul Sewer Repair Permit. 100.00 100.00 �
35.00! ` Feet of 6" Sch.40 PVC Pipe, Fittings, &Couplings. 5.29 185.15 ;
1.00' ' Concrete Manhole Blocks,Brick, &Cement. 186.18 � 186.18 ',
4.18'' Tons of Cold Patch Blacktop 42.80 i 178.90 j
19.50! 1250 ! Tons of Class-5 Base Materials ( 4.75 92.63 ;
28.44' 1260 i Tons of Sand 7.b0 � 216.14 i
3.00! 1240 � Loads of Rubble or Mud dumped @ Area Dump site 35.00 � 105.00 �
1990 � 20%Overhead&Profit on Total of Above Items. ! 218.80 i
; ' ($1,064.00) � ��
25.00� 1010 Hours Foreman-Regular time 62.50 : 1,562.50 !
2.00 1020 Hours Foreman-Overtime 9d.25 '': 180.50 �
26.50 1070 , Hours Laborer-Regular time 44.50 ; 1,179.25 '
I I �
I � — I
I
Subtotal Continued �
Due Date: March 2, 2001 Sales Tax Continued �
Total Invoice Amount Continued '
Check No: Payment Received _ Continued �
TOTAL � Continued i
1.5% per/month service charge on invoices past 30 days from invoice date.
Invoice
Webster Company, Inc.
845 Edgerton Street invoice Number:
P.O. Box 17124 18842
St. Paul, MN 55117-0124 Invoice Date:
Voice:��5�1)�76-2733 Jan 31, 2001
Fax:(651)778-8815 Page:
2
Date. Descriqtion of Work. & Jobsite:
Sold To: Dan Ferstenou Dec. 28,2000 & 1/4-5-8,2001
1935 Sheridan Avenue Repair sanitary sewer
St. Paul, MN 55116 1935 Sheridan Ave.
St. Paul, MN
--- _ ___ __ ,_ _ -- -------- — --.
Customer ID Customer PO Pa ment Terms '
_ _ ._.------ ---- --
1924 ' Nef 30 Days
� �
------ � ---_ _-- I'
- ------ _-- -- ___ ----- -_ - - __- __---__-----_._.--_- I
Quantity Item Description Unit Price Extension
____ _ _ _ ___---- --
2.00 1080 Hours Laborer-Overtime 58.75 , 117.50 �
25.00; 1095 Hours Operator(No Equipment)-Regular time i 48.50 i 1,212.50 !
2.00� 1096 Hours 4perator(No Equipment)-Overtime 64.50 129.00 ;
3.00 Days Use of 5�5 Ford Loader with Backhoe Attachment 296.39 889.17 I
10.50 1230 Hours Tandem Dump Truck&Driver 60.00 630.00 �
1.00 Days Use of Trench Box 105.00 105.00 ',
l.50 1170 Days use of Turtle Tamper � I 50.00 225.00 '
4.00 1160 Days use of Crew Truck 1 25.00 100.00 �
1994 SUBCONTRACTORS &NONOWNED EQUIPMENT
RENTALS '
Kobelco l50&Breaker-Hayden Murphy 1,799.21 �
Barricades-Warning Lites 97.04
Permanent Street Patch -City of St. Paul 1,400.62
Transport Equipment- Semple Trucking 340.00 ;
� Clean Drill Hole- Infratech Co. 720.00 ';
1992 10%Overhead on Subcontractors&Equipment Rentals. ; � 435.69
($4,356.87) !
�
I NOTE: The City will install the permanent street patch I
in the Spring. This invoice does not include any �
additional restoration. j
; �
I
� i
i
;I
�__-_____.__. _ _�
___I
---. �
Subtotal 12,405.78 �
Due Date: March 2, 2001 Sales Tax
Total Invoice Amount 12,405.78 �
Check No: ; Payment Received � 0.00
._ __ _.__.
__}__---- _ .
TOTAL � --. __ _._._12,405.7$ _;
1.5% per/month service charge on invoices past 30 days from invoice date.
Invoice
Webster Company, Inc.
845 Edgerton Street Invoice Number:
P.o. Box 17124 188421
Invoice Date:
St. Paul, MN 55117-0124 Apr 30, 2001
Voicej651)776-2733
Fax:(651)778-8815 Page:
1
Date, Description of Work, & Jobsite:
Sold To: Dan Ferstenou March 27, 2001
1935 Sheridan Avenue 1935 Sheridan Ave.
St. Paul, MN 55116 St. Paul, MN
Customer ID Customer PO Pa ment Terms ___
_...._..___ -
1924 � Net 30 Days
____. __ -
_._____ ---
Quantity ltem � Description Unit Price i Extension
� We are required to maintain the temporary street
� patch until the permanent one is installed by the City.
� The City Street Maintenance Department called &
! told us that the patch was failing.
3.00 i Tons of Asphalt 26.50 79.50
1.00� `Equipment&Labor to Install 581.90 581.90
� �
!
�
�
j i
i
i
�
� � --
Subtotal 661.40
Due Date: May 30, 2001 Sales Tax
�Total Invoice Amount 661.40
Check Na I_ Payment Received } 0.00
� TOTAL I 661.�
1.5% per/month service charge on invoices past 30 days from invoice date.
HEGRANES LAW OFFICE, LLC
� 1532 Sargent Avenue
St. Paul, MN 55105
651-398-5152
sphegranes@qwest.net
March 28, 2001
Dan & Amy Ferstenou
193 5 Sheridan Avenue
Saint Paul, MN 55116
Dear Dan & Amy:
Enclosed please find a check made out to Dan in the amount of$5,500.00 in payment of the claim against
the Roing's for sewer repair. Also enclosed is an invoice for my services.
Thank you for this opportunity. Please feel free to call me at any time with additional questions related
to this or any other matter.
Sincerely,
,
;� �
!�r
, Z�.�-N��i` ��N �_-����
: ,,�` ,, �
�Steven Hegranes
Enclosures