Castelan (3) RECEIVE�
�tf Q41��1 1681 Saunders Avenue
�^� St. Paul, MN 55116
V September 4, 2012
City Clerk
15 West Rellogg Blvd.
310 City Hall
St. Paul, MN 55102
Ref: Notice of Claim Form submitted for damage to basement at 1681
Saunders Avenue from sewer back-up on August 7�
To the City Clerk of St. Paul:
Attached you will find the report from American Leak Detection as well
as a copy of the video (DVD) that was taken of our sewer line on August
10, 2012. These items are to supplement the documents that accompanied
our claim for damages caused by the backing up of the sewer into our
basement on August 7th (submitted on August 27`�) . You will see from the
report and the video that there was no blockage or obstruction in our
line from the house to the main line at the street.
We hope that this will be sufficient evidence to support our claim that
the extensive damage done by the backing up of the sewer system into
our basement was caused by the testing work done by S.E.H. on our
street that morning.
We hope to have this settled as soon as possible so we can get our home
back into normal condition soon.
Please do not hesitate to call us if you have any questions related to
this matter: 651-690-9999 (home) or 612-812-3456 (Anselmo cell) .
Sincerely,
l
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Liz Hathaway Castelan and A elmo Castelan
Attachments:
• Written report from American Leak Detection
• DVD of sewer line of 1681 Saunders Avenue, St. Paul, MN 55116
• Copy of original Notice of Claim Form submitted on August 27th �
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�►,rr' L�AK PoBoX411ss
''"'�' DETECT=011i plymouth, MN 55441
THE ORIGINAL LEAK SPECIALISTS' PtlOrie: �63-263-���3 DATE INVOICE#
F�: 763-263-7773
8/10/2012 12043
BILL TO Job Site/Phone#
American Family Insurance Anselmo&Elizabeth Castelan
Attn:Joe Cieminski 1681 Saunders Ave.
6000 American Pkwy St Paul,MN 55116
Madison,WI 53783 Claim#815-000780
P.O. No Start Technician Referral#
Sl10/2012 J5 OlIns
Completed Date Service DESCRIPTION AMOUNT
8/10/2012 Source&origin Evaluation and inspection of property was performed to investigate 350.00
suspected water damage claim.
Camera inspection was performed from cleanout at front of home to
main line at street. No breaks,collapses or other problems were
noted in line at time of inspection. Further evaluation revealed
line did not have a backflow preventer at time of inspection.
Residence was lowest home on line from the City main line at
street.
DVD of entire inspection was provided for documer►tation.
Repairs to be performed by ot6ers.
Work ordered by Joe Cieminski.
Thank you for the opportunity to be of service to you. Jay
uaran ee on e ec ion: ea oca�on e ec�on wo is guaran ee or ys om
date of completion.We will re-test the system,if it is reported within the 30 day period Total $350.00
that the same leak exists. Vinyl liner detections are guazanteed for 48 hours only.We will
not be liable for any other consequential losses.
Guarantee on Repairs: Minor repairs are guaranteed for 30 days.Major repairs are Balanee Due $350.00
guaranteed for 12 months.All repairs are guaranteed from date of completion and for
defective workmanship only.We will not be liable for any other consequential losses.I find
the work satisfactory and the charges as agreed,and agree to pay the total amount on
presentation of this invoice without any deduction whatsoever.
I further agree to pay reasonable charges for collection,including attorneys fees,in the
event of mv default as well a�nenaltv interest as allnwed hv law.
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NOTICE QF CLAIM F4RM to the City of Saint Paul, Minnes,�- ��'1
' hlinnesota State Statute 46�US states thnt °._. rs O�
°1' }� rpal: �ithin 1811 '� on_..who clairas danrages from mry murrrcipality...shall cause to be presente
S er�S bodl'o the raunic" 'ty days aJter t�ie alleged tass or i�yury it discovered a notice stating the time,ptace,and
- cirewnstantes there�'mrd the mnoernt of conq�ensation ar other relieJ'denrm:ded•,
Please compiete this form in its entirety by clearlY tyPing ar Frinting yoar answer to each qnestion. If more space is
needed,attach additional sheets. Piesse nots that you wy not be contacted by telep6one to clarify ansyyers,so provide as
mnch information as necessary to ezplain yc►�r clai�,and the amoAat of compensativn bei�tg reqaested. You wili receive a
writtea acknowledgement once your form is received. The procesg can ffike ap to ten weeks or longer dependfn�g on the
natnre of yonr claim. Thic form must be signed,and both gages complc#ed. If something does not sPPiY�write`N/A'.
SEND CUMPLETED FORM AND pTHER DUCUMENTS TO. CITY CLERK,
15 WEST KELLOGG BLVD, 31fl CITY HAI,I.,, SAIlVT p��3I,, � 55102
First Name_�nS��r»ta 1Vliddle Tnitial C - Last Name �p 5�}��i�Y► �L t l�a.��qv�Y Ct�S�'�u��
Company or Business Name I S 4 R ?
Are You an Insurance Company? Yes No If Yes,Claim Number? `�� ��1 c�{�, i�a �{»+�c. Fc�►.,,.•1 r�S, � �
� r.ia�rv� � S1S�n�sr � �, �
Street Address R�t 2 �, C°' "I�
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City `j`�' �c�� State�/{� Zip Cvde '—�/1 � r,� h;
Daytime Phone(�p$7)�Y�-q999 Cell Phone 61?�. !2�Sb Evenin Tel � ¢ C'i
g e�hone l�c sI )�p-R R99
Date of Accident/Injury or Date Discovered�_�_���} � �j� Z Time l0:O 0 ?�/p�
P lease state,in d e t a.il,what occurreci(happened),and why you aze submitting a claim.Please indicate why or how you
feel the City of Sa.int Paul ar its emplayees are mvolved and/or�esponsible for yaur damages.
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Please check the bolc(es)that most ciosely iep�ant�he��on f�� � °���
❑ M vehicle was P�g�f°��
y ��a m��!� ❑My vehicle was damaged during a tow
�My vehicle was damaged by a pc�thole or condition of the sfi�eet C7 My ve�icle was dainaged by a plvw
❑My vehicle was wrongft�lly tow�and/or ticketed ❑I was injured oa City P�P�Y
�Other type of Pt'aPerh'damage—Please sp�if3'_�v_tr, av,c� o r oP��v �vn�ae -h b�w�en'}'
❑Other type of injury—plea.se s��ecify
In order to process your claim you need to inciude conies of a�l�nalicable documents
For the claims types listed below,please be sure ta inch�de the dacuments indicated or it w�i delay tt�e handling of
your claim. Documents WILL NOT be relurned and become the properiy of the City. Yo�are encouraged to keep a
copy far yourseif before suhmitting your claim form
O Properiy damage claims to a vehicle:two estimates for the re�irs to your vehicle if the d��tma.ge earceeds
$540_OQ;or the actual bills and/or receigts for the repairs
O Towing ctaims: legible capies of any ticket issued and a copy of the impc�und lot receipt
�f Other groperty damage claiins:two repaa estimates if the damage exceeds$SOQ_D0;or the actual bills
and/or receipts for the repairs;detailed list of damaged it�ems
O Injury claims: medical bi11s,receiPts
O Photographs are aiways welcome to dc�cumen#and support your claim but will not be retumed.
Page 1 of 2—Please complete and retarn both pag+es of G7aim Form
Failure to complete and retnrn both page����t�delay in the l�aadling of your claim,
� All Claims—Dlease comaIete this section �
Were there wimesses to the incident? (y� ) NQ
Provide their names,addresses and telephone n�i��; U�O� ��'��e)
� �- . „ ar -��la� <s t�+s re,a.T�� a�d
. -� Sev.i 5
Were the police or Iaw enforcement called? y� No •
If yes,what department or agenc� Unknown (circle)
Case#or report#
Where did the accident or injury take place? provide street address,cross stree
closest landmarl�etc, please be as detailed as possible. If nece �mtersection,name of park ar facitity,
_�(og� �avnclers /��te,�.�� ��,. F ,.,� �rY�attachadiagram-
, M� 5 S� � (,.
Please indicate the amount you are seeking in�ampen�i�II or what yflu would 1�1ce the City to do to resolve this claim
to your satisfaction.�� q�. 0 O
Vehicie Claims— lease com lete this section
Your Vehicle: Year ❑check if this section does not a 1
M�e Model
License Plate Number e Co10
Registered pvyner
Driver of Vehicle
Area Da,maged
City Vehicle: Year Make odel
License Plate Number State Co1or
Driver of Vehicte(Cii�'EmPIa3'ee' ame)
Area Damaged
In'u Claims— lease com lete this� 'on ❑check x if this sedion does not 1
How were you injured?
What part{s)of your body were injured?
Ha.ve you sought medical trea.tment? yes No planning to Seek Treatiment(circle)
When did you receive treatinent? (provide date(s))
Name of Medical Provider(s):
Address Telephone
Did you miss work as a resEilt of your injury? y�
When did you miss wark? (provide date(s))
Name of your Employer.
Address Telep e
�Check here if yon are attac�ing more pages to this claim form.'Nnmber of additional pages��/�°�1' ,
By signing this fvrm,you are stating that all infarmat�ion you have prm�ded is true and corred to the best
of your knowledg� U�rsigned forms will not be prncessed ,
I
Submitting a false claim carc result m prosecutiom. Date form was completed �uQ�S �- aS ��
a.�r.�.
Print the Name of the Peison wLo Completed this Form: Q S � �
Signatnre of Person Mal�ng the Claim: ' an d v►S cl w,c CaS��la»)
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Revised February 2011
,
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