Camozzi NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
Mtnnesota State Statute 466.05 states that "...every person...who claims damages from arry municipality...shall cause to be presented to the
governing body of the municipality within 180 days after the alleged loss or injury is discovered a notice stating the time,place,and
circumstances thereof,and the amof�nt of compensation or other relief demanded."
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 rec�ived. 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 I�ELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102 ;
First Name �� Middle Initial � Last Name ��/V�4��' ,
Company or Business Name ,
Z��
Are You an Insurance Company? Yes N/� If Yes, Claim Number? '
Street Address � � �I°�—C1tJ��11�1 �'`�� ����'�� I
N �� � �
City �'�. �Ol�L I State M Zip Code �
Daytime Phone(b I�)Zl�-O� Z Cell Phone�) Evening Telephone�� _
(�� th� �
Date of Accidenb Injury or Date Discovered T ���Z-��Z�IZ Time am/pm
Please state,in detail,what occurred(happened),and why you are submitting a claim.Please indicate w y or ow y u
feel the City of Saint Paul or its employees are involved and/or responsible for your damages. ' �
l
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
0 My vehicle was wrongfully towed and/or ticketed �I was injured on City prope
hd'Other type of property damage—please specify �i °�Q
❑ Other type of injury—please specify
In order to process your claim vou need to include conies 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 properly 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
4?'Other property damage claims:two repair estimates if the dama e exce�ds$5.00.00; or the actual bills •
and/or receipts for the repairs;detailed list of damaged items -1V1G�w1�lZ'
O Injury claims: medical bills,receipts
C�'hotograp s e always welcome to document and support your claim but will not be retumed.
�ycovc�e� �o R,;�,1�� C�cobe�� � c�c.�nurd��ckQ�t�C��;.���omn.k5
Page 1 of 2-Please complete and return both pages of Claim orm
Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims—nlease comnlete this section .
Were there witnesses to the incident? Yes No own, ( ircle)
Provide their names,addresses and telephone numbers: �n Q o
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 park 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 ike the City to do to resolve this claim
. to your satisfaction. 'i�vt Krae�tn of (� � �'����P� �� ►�� �°
� Vehicle Claims �lease comQlete this section B�check box if this section does not annlv
I Your Vehicle: Year Make Model
License Plate Number State Color
Registered Owner ' ' �
Driver of Vehicle
; Area Damaged
i
City Vehicle: Year Make Model
License Plate Number State Color '
� Driver of V�hicle(City Employee's Name)
I Area Damaged �
InLrv Claims—nlease cam,.plete this section �check box if this section does not annlv
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
l�Check here if you are attachirig more pages to this claim form. Number of additional pages
i By signing this form,you are stating that all information you have provided is true and correct to the best
i of your knowledge. Unsigned forms will not be processed
- � �
Submitting a false claim can result in prosecution. Date form was completed , i ��
Print the Name of the Person who Completed this r : � `� ��0 �
Signature of Person Making the Claim:
Revised February 2011
Jeff&Liz Camozzi
1929 Sheridan Ave.
St. Paul,MN 55116
612-217-0422
To whom it may concern:
This letter is a description of the property damages and costs my wife and I incurred
due to a sewer pipe breakage on the drill hole in the middle of the street in front of
our house. Richard Ekobena, City of Saint Paul Sewer Department, informed us that
this pipe is owned by the city,and we should submit a claim.The following is an
outline of key points and timelines:
• Fall 2011 -Spring 2012
o During this period we would notice an occasional small flooding on
the unfinished half of our basement.
o We never saw the issue occur.We only discovered wet flooring and
rugs after the flooding occurred.
o After the third time this happened I decided to have our main drain
and secondary drain cleaned out under the suspicion that the flooding
came from there.
• July 7, 2012
o I contacted S.O.S. Drain&Sewer to perform a main-line and
secondary-line cleaning.
o Brad Bartell of S.O.S. performed the work and cleaned our drains.
• Mid-August, 2012 �
o Another incident of flooding happened.We observed fully damp rugs ,
on unfinished side of the basement,with water trailing to the finished ;
side. ,
o We contacted SERVPRO to see if they could find the cause.The I
representative came out to look,but could not find any immediate �
issue. He left without charging us.
i
• August 23, 2012 I
o We saw the flooding occur first-hand and called S.O.S Drain&Sewer �
to come look at the issue.
i
o Brad Bartell returned to clean the drain again,but discovered that
even going 100 ft. out from the house,the drain still had water in it.
o By this point he contacted the City Of Saint Paul Sewer Department
and learned that we did not have a standard sewer hookup.We were
informed that we had a"Drill Hole"that went from the middle of the
street straight down 70 ft.through sandstone to a main sewer line.
o To correct this issue we would have to contact a specialized
contractor.We were informed that even though the drill hole was on a
public roadway it was our responsibility to fix the issue.
o We were given the contact information for Grant Engen with Grant
Utilities Inc.
• August 24, 2012
o Grant visited our house to review the issue with us. Brad Bartell also
returned to assist Grant in televising the sewer line and validating the
drill hole was in the middle of the street.
o We were sent a quote of work for$5,000 to open the road and inspect
the damages,and$2,150 to install a better main-line (by converting
the clay pipe to PVC). Grant informed us that any repair to the drill
hole would be an extra cost.
• August 28, 2012
o I was out of town in Chicago for work. My wife came home from work
to find the entire basement flooded with sewage water(including
fecal matter).
o I contacted SERVPRO of Northern Ramsey County to assist in the
cleanup of the flooding.They arrived and did an initial clean,leaving
equipment to dry the basement.They would later come to remove and
clean all our damaged personal items,and remove any items that
were damaged or soiled beyond repair. Note that the bill from
SERVPRO went directly to the City of Saint Paul.
• August 29, 2012
o Work began on the road early morning (about 7:00 AM).
o Grant discovered that the extent of the damages were severe and
contacted the City of Saint Paul Sewer Department. From my ,
understanding there were a number of exchanges,but ultimately we
learned that the City had taken ownership of the drill hole, and would
be covering the costs and the damages for repair.
o Richard Ekobena contacted my wife and I to inform us of the situation, �
and visited us later in the day to take pictures and provide us with a ;
claim form. '
o Grant connected with us to let us know the bill for the drill hole ;
repairs would be sent directly to the City of Saint Paul.We did elect to
pay for the replacement of our clay pipe main-line with PVC Pipe,and �
wrote a check to Grant for$2,150. ';
• August 31, 2012 -October 15, 2012 I
o During this time period the following things occurred: I
■ SERVPRO finished cleaning our basement.
• Hauling away damaged property. Of which the most
costly items were our laminate flooring,love seat,
shelving units,and a moderately priced suitcase.
• Disinfecting and drying the entire basement floor.
• Disinfecting any personal items that could be saved.
■ Due to raw sewage on our floor we had to remove vinyl tiles
installed by the original owners.SERVPRO suspected these
tiles would have asbestos,and had them tested.The test
showed the tiles had 3% asbestos.We had to have Twin Cities
Abatement Technologies, Inc.properly remove the tile.The
cost of this was $900.
■ During September we contacted Floors of Distinction to
request a re-install of the flooring.This is the company who
installed the floor previously a year ago. Due to work and
personal time constraints we asked them to move forward and
install the floor after the tiles were removed.The total cost of
this was $1,649,which was close to the original cost to install
the floor a year ago.The floor was installed October 15, 2012
and we received the final invoice that week.
We have sent pictures documenting the damage to Richard Ekobena.The property
items listed are as close to the original items as we could find. Not listed in this
documentation is an estimated$100 to$200 worth of damaged books,which was
included in the pictures we sent.
We hope this letter appropriately outlines the situation and reason for this claim.
We are certain any questions regarding what was communicated to us can be
corroborated with Richard Ekobena.
Sincerely,
Jeff oz i
i
;
Liz Camozzi
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Primary Witnesses:
GrantEngen
Grant Utilities, Inc.
553 Como Avenue
St. Paul, MN 55103
651-793-5251
Brad Bartell
S.O.S. Drain&Sewer Cleaning Services, Inc.
P.O. Box 22069
Robbinsdale, MN 55422
612-721-5413
Dan and Amy Ferstenou
1935 Sheridan Ave
St. Paul, MN 55116
651-669-5888
Richard Ekobena
City of Saint Paul
651-566-9990
SERVPRO of Minnetonka
2305 Louisiana Ave N.
Golden Valley,MN 55427 �
952-473-4837
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MAIN SEWER LINE GUARANTEE: lines are guaranteed for 30 days from the
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Water & Sewer Service
CUSTOMER CONTRACT
August 24, 2012
Jeff Camozzi
1929 Sheridan St.
St.Paul, Mn.
Description: Excavate and repair sewer service at cleanout riser
Tlus price includes asphalt restoration of 8x7 finished dimensions
This price dces not include tunnel inspection/repairs or drillhole repairs
_ .-�-�,8�.ee�--, ���r� b� c i�� �� 5� ��t�, �
This price includes: all labor,materials,permits and ins�ctions
Optional wo " 40 pvc from basement to cleanout riser
Add$ 2,150.00 to above pric� �0�►� �j Vt j .
A w orme �
d m a�ourneyman-hke manner to meet or exceed crty requirements for
this repair.
GUI is not responsible for failure of existing internal plumbing and fixtures. GUI is not
responsible for restoration of trees, shrubs, grass, sidewalk, curb, steps, railings,retaining walls,
driveways or other structures,permanent or temporary, unless otherwise specified.
I
GRANT UTILITIES, INC. I
By:o rcrnt e� �.n�en
Its Chief Executive Officer
553 Como Avenue • St_Paul,MN 55103 • Ph:651-793-5251 • Fax:651-793-5257
� License# 19990003441 Member American Water Works Association
--r- www.grantutilities.com
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CAMOZZI
Floors of Distinction FLOORING QUOTE
12642 Bass Lake Road
Bass Lake Center
Maple Grove,MN 55369 DATE OF ORDER: 9/M2012
763-553-1g0� ORDER TAI�N BY: COLLEEN
WWW.tloorsofdistinction.COill INSTALLATION DATE:
TO: JEFF 8� LIZ CAMOZZI REFERRAL: REPEAT
1929 SHERIDAN AV MATERIALS:
ST PAUL, MN 55116 �M���
PHONE: 612-217-0422
Pos
EMAIL: �effcamozzi mail.com REF#�
- � • 1� • • - • � •
LL 10 CTNS 293.5 EVOKE MABLE-ANTIQUE MAPLE 5.24 1 537.94
29.35 SF/CARTON
INSTALLED
Fioorin Subtotal: 1537.94
� � � � � . - . ! � �
REDUCER 1 39.99 39.99
SQUARE NOSE 2 35.99 71.98
Add'I Materials Subtotal: 111.97
. � . - � ' �
Misc.Subtotal:
NOTES: SUBTOTAL 1649.91
AMOUNT TO BE TAXED: TAX
GRAND TOTAL 1 649.91
DEPOSIT
BALANCE DUE 1 649.91
TERMS:FULL PAYMENT UPON ORDER. VISA, AMERICAN EXPRESS,MASTERCARD AND DISCOVER. IINPORTANT: Prices are good for accepta�ce and delivery for 30
days only,unless such time is extended in writing. CUSTOIIIIER READ BEFORE SIGNING: 8uyer understands that there may be a dye-lot variation from sample. Seller is not
responsible for chips,dents or conditions of existi�g moldings,doors,jambs,w fuctures. Room must be clear of obstaGes at time of installation. Seller is not responsible for
customer's measurements.Seller is not responsible for manufacturer or shipper delays. Unforeseen structural problems upon installation may change the amount due on this
invoice.
1/WE THE BUYER(S) HEREBY ACCEPT THE ABOVE TERMS AND CONDITIONS Signature:
�I'.C.A.T. INC` .
Twin Cities A�ratement �echnologies, Inc.
11f�f?N. C�ancord �t.
So. �t. �I'aul. ?�'1� >��7�
�j O�.
']`he undersigned ackna��ledges the receipt �f the sum of: �__J��---- ----------
Frorn�:_ ��`��—_��_r✓I.Q_Z�!_ __ ___.
_ J__l�z�---������_A�--
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� __��-:P 1_, _��=—�s'-%
Chectt only ane:
�) _._as partial payment for tabor, materials and permits furnished
2)� as payment for all labor, materia4s and permits furnished
(except the sum of�_______ ___.__—_retainage}
3)____�� as futl and fival payment for atl labor,materials and permits furnished iz� the
following described real pro�er�ty: (legal description, street address or project name}
��,�,m z _�,._�_�b__c_�._ . _-
_�1�,� ��=,_13�_����.e,�',-- -
and for valt�e received hereby waives all rights acquirQd b� the undersigned to �Ie t�r
recard mechanic's liens against said real propertr� for labor,materi�als or permits furnished
to said real progerty { ont��for the amount paid if Box l is checked,and except retainage
shown if B�x 2 is checked ). The undersigned affirms that all materials furnished bti the
u[tdersigned has been paid for, and a11 subcontractors empEoti�ed hy the undersigned hat�e .
been paid in full.
Note: If tbis instrument is exeeuted by a cor�oration,it must he signed by a❑ offcer, and if
bz� a partnership, it must be signed by a �artner.
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Name Si�►ature
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Date
�a `�� save up to SO%on select Halbween costurtt�s.plus, "' '"' Med these yeR?bright fdea
free shipphg wi�en you spend 550.Halbween � �� �r� leam more
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