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Fenster NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota Minnesota State Statute 466.05 states that "...every person...who claims damnges from any municipality...shall cause to be presented to the governing body of the municipaliry within 180 days after the alleged loss or injury is discovered a�totice stating the time,place,and circumstances thereof,and the amount 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 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 PAUL, MN 55102 �ECE���� First Name � ��a�� Middle Initial S Last Name ��n�t��' Company or Business Name " NOV 0 9 2p�2 i Are You an Insurance Company? Yes/No� If Yes,Claim Number? ��� ��w��K j Street Address �3�'6 �1 �.� hc'r �.�c�; � E City �� ����'�-�%�oc� State � N Zip Code SS � �� Daytime Phone(�)2�6_9SL7Cell Phone ( ) - Evening Telephone(9S�)�E;- �h�%f'> Date of Accidend Injury or Date Discovered �>�°� � �� Time�_am/�i„ 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 dama�es. r v:..r wc�t�r rv�t tC; w�s o.,� c; r+��i., H tl�.c�t' L�le,..� �--yh. (� 5�. 1��.� 1 w�f��- WA S `.>->p,- �'..-�ci �� O�",' F+��C0. . ��1t wc.tC:' iv�f'tC° C'..abb-1 �C ��SCt �. ��CZ'� �^'�t�l t�-X'c�C.-- fiL.z.'� Sac1#�rc� thrc�,.�.r� t4�t t�r.� c--y�I I u.,c� �..v�t��.- �"he �/c�.Y,.'.-.ta ��rtv fi6.r i � � �CS..�✓Cr \��Z� bt't�/t�iJ�,�• '� �.c[ ��'�•vr'�.7,. ��G C ot r PC��S d'. ��.�.� w�` t' w l�:'l' PciV i(`7 SA�Vi�'il'c°�1 l�t �*trr�l�t��•v.� Ca.»Pqn�-f `^'��S Csci��tC� G�.i� lci C.�IrN t��%Co'�rih�nR : �� STc`t..��.1G� (,•.xi'y I�'�t On tX►E f.��SF���S � �wLl�, �rl�C:� i5 �Oi�n�.nt� firT` Wi'1^ �.G/Y�S �� �� i.ln�f:'!"L141�J SC'i' 1'/����� nl '=��c,: +'1`„�t��C�r.�wr,�� `f Cc.rPi'f 5�,�,..sti .c��, � wr,il (�q�c':' C:lc:.rct�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 ❑ My vehicle was wrongfully towed and/or ticketed ❑ I was injured on City property j�,Other type of property damage-please specify �7r� �ti.,I� '� W�I I P=���% �1�M°��,<cl b�r r�P�-�o�'� ""�,.��r �— •'''�.�}��' ❑ Other type of injury-please specify In order to process your claim vou need to include copies of all apulicable 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 i O Towing claims: legible copies of any ticket issued and a copy of the impound lot receipt ' O Other property 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 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-please complete this section Were there witnesses to the incident? es No Unknown (circle) Provide their names, addresses and telephone numbers: �- ����C+-� ��S h�•��- S f• p�`^ � �,� W c,���' ��+'� -�C S�c�'�C"�� �'--1 f" C G v..�v�<61't � �t �n ' �c�C. 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. Z�3�%C� i����c� �rc : � C. N��a�OIC,.-��oc�� M!�( S�1 Ir1 Please indicate the amount you are seekin in compensation or what you would like the City to do to resolve this claim , � , I to youlr satisfaction. w�I u 5� a: `� l� � Z�: S� f��' ��.���l�'f��'� {� ��' ' � C9�f�4wi} �1 � WAII (ki0�t �J ilS p,_.;�, ,Ze� � Co��,c:�i �t.o,7.. 1 Vehicle Claims-please complete this section '�check box if this section does not avvlv 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 complete this section �,check box if this section does not apulv 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 ❑ 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 of your knowledge. Unsigned forms will not be processed. Submitting a false claim can result in prosecution. Date form was completed �d v� ��� Z v f Z Print the Name of the Person who Completed this Form: �- �i�^��*�'� rt•'�S�P'' Signature of Person Making the Claim: Revised February 201 I �RES7ORATION Restoration Professionals rROrESSiana�s 505 Minnehaha Ave.W. Saint Paul,MN 55103 Phone: (65])379-1990 Fax:(651)379-]99] License#BC396147 Client: Curtis Fenster Home: (952)466-6688 Property: 2306 Timber Trail East Maplewood,MN Operator Info: Operator: RTONI Estimator: Rodny Toni Cellular: (651)236-7266 Position: Estimator E-mail: RTONI@restpro.com Compa�y: Restoration Professionals Business: 505 Minnehaha Ave.W St.Paul,MN 55103 Type of Estimate: Date Entered: 10/8/2012 Date Assigned: Price List: MNMN7X AUG12 Labor Efficiency: Restoration/Service/Remodel Estimate: FENSTER-CURTIS We appreciate our customers and will do everything in our power to ensure their complete satisfaction when the project is complete,using good judgment at all times. If conditions differing from our estimate are identified,Restoration Professionals should be contacted immediately to review these conditions and determine if they have any impact on our opinions and recommendations.The following estimate is contingent upon your approval.Any work performed above and beyond this estimate will require a CHANGE ORDER in advance. i ; I� :sES�oru►noN Restoration Professionals •PftOFESSiONA�S' 505 Minnehaha Ave.W. Saint Paul,MN 55103 Phone:(651)379-1990 Fax: (651)379-1991 License#BC396147 FENSTER-CURTIS Main Level f-,�',�"-� Bedroom Height: S' � ,o,4„ � a�a�„ F3'z T 396.00 SF Walls 146.86 SF Ceiling � M m m 542.86 SF Walls&Ceiling 146.86 SF Floor - � 1632 SY Flooring 49.50 LF Floar Perimeter 1 ,�e. _ N 49.50 LF Ceil.Perimeter , ,42��� m DESCRIPTION QNTY REMOVE REPLACE TOTAL 3. General Demolition-per hour 2.00 HR 44.04 0.00 88.08 Demo out the rest of the drywall that was opened up to get to the meter and was wet 16. Natch/Access door 1.00 EA 0.00 255.80 255.80 17. Drywall patch/small repair,ready for 1.00 EA 0.00 58.76 58.76 paint l9. Drywall Installer/Finisher-per hour 1.00 HR 0.00 66.05 66.05 fitting in drywall around new door and framing 6. Baseboard-Detach and reset 10.00 LF 0.00 2.39 23.90 9. Carpenter-General Framer-per hour I.00 NR 0.00 62.67 62.67 10. Painter-per hour 1.00 HR 0.00 47.16 47.16 paint 1 coat on walls being worked on only....at homowner's request. 11. Floor protection 36.72 SF 0.00 0.45 16.52 Totals: Bedroom 618.94 OPen Height:8' �-3�a�--� 65.33 SF Walls 3.54 SF Ceiling T � �a�;� � 68.88 SF Walls&Ceiling 3.54 SF Floor 1 0.39 SY Flooring 8.17 LF Floor Perimeter 1 I-3�2" 8.17 LF Ceil.Perimeter I I DESCRIPTION QNTY REMOVE REPLACE TOTAL � 7. Seal the walls and ceiling w/anti- 68.88 SF 0.00 0.94 64.75 microbial coating-one coat FENSTER-CURTIS 10/22/2012 Page:2 �RES��oR,anoN� Restoration Professionals PROFESSIONALS 505 Minnehaha Ave.W. Saint Paul,MN 55103 Phone:(65l)379-1990 Fax: (651)379-1991 License#BC396147 CONTINUED-OPen DESCRIPTION QNTY REMOVE REPLACE TOTAL Totals: OPen 64.75 Total:Main Level 683.69 General DESCRIPTION QNTY REMOVE REPLACE TOTAL 1. General clean-up l.00 HR 0.00 30.08 30.08 8. Haul debris 0.25 EA 123.22 0.00 30.81 Totals: General 60.89 Hallway DESCRIPTION QNTY REMOVE REPLACE TOTAL 12. Remove Wallpaper 480.00 SF 0.65 0.00 312.00 13. Texture drywall-smooth/skim coat 480.00 SF 0.00 1.05 504.00 , 14. Prime new skim coat-one coat 480.00 SF 0.00 0.38 182.40 ��, 15. Paint the surface area-two coats 480.00 SF 0.00 0.66 316.80 �� I 18. Floor protection 48.00 SF 0.00 0.45 21.60 Totals: Hallway 1,336.80 Line Item Totals:FENSTER-CURTIS 2,081.38 FENSTER-CURTIS 10/22/2012 Page:3 I I �,,RESroHanoru Restoration Professionals PROFESSIONALS 505 Minnehaha Ave.W. Saint Paul,MN 55103 Phone:(651)379-1990 Fax:(65l)379-1991 License#BC396147 Grand Total Areas: 46133 SF Walls 150.40 SF Ceiling 6l 1.74 SF Walls and Ceiling 150.40 SF Floor 16.71 SY Flooring 57.67 LF Floor Perimeter 0.00 SF Long Wall 0.00 SF Short Wall 5'7.67 LF Ceil.Perimeter 150.40 Floor Area 168.82 Total Area 46l 33 Interior Wall Area 469.50 Exterior Wall Area 52.17 Exterior Perimeter of Walls 0.00 Surface Area 0.00 Number of Squares 0.00 Total Perimeter Length 0.00 Total Ridge Length 0.00 Total Hip Length �i II FENSTER-CURTIS 10/22/2012 Page:4 � RESrow►noN Restoration Professionals �PROFESSIO�ALS'. 505 Minnehaha Ave.W. Saint Paul,MN 55103 Phone:(651)379-1990 Fax: (651)379-1991 License#BC396147 Summary for Dwelling Line Item Total 2,081.38 Matl Sales Tax Reimb @ 7.125% 26.98 Subtotal 2,108.36 Overhead @ 10.0% 210.87 Profit @ 10.0% 2]p,g7 Cleaning Sales Tax @ 7.125% 2,5� Replacement Cost Value $2 532.67 � Net Claim $2,532.67 Rodny Toni Estimator � i FENSTER-CURTIS 10/22/2012 Page: S �� _ _ . __ _ Insured: Curt Fenster I�ome: (651)216-9827 Property: I�ome: 2306 timber trail Maplewood,MN 55199 Estimator: jared tix Claim Number: Policy Number: Type of Loss: Date of Loss: Date Received: Date Inspected: Date Entered: 10/21/2012 8:03 PM Price List: MNMN7X OCT12 Restoration/Service/Remodel Estimate: CURT-FENSTER � � ' '�.,�.,.: city widxestorationinc.com L�3ja�V�`zy"'4'7t7ci"ti �€lL�i(;. i✓G;r�1�ur}-; ��1N `'.�>.`.25 �t?!.D C�::!�ens:e; T_� r ,��` �.,,,,� �,�,�, �>., . Water damage +";;;tt lS,�rYC= �.1.� `siC7l3E's!Z tJ, c, ;=Cf' ' lC�s`,.�yi 1 Construction,painting and wallpaper removal $948.50 1 Remediation $175.00 ' i ' ' i Subtotal '; $1123.50 Sales Tax Totai ' $1123.50 .�'":��at�k�;�au fo;-yaur�t�lfslrre:=ssf �fxcar��.� �`f�'-��9-222�' �-r��t��r°� 1.�.`'y��r7cl�ytvi�erest�re�t%anir�,�.cr�rr� CURT-FENSTER Main Level Basement Height: 8' DESCRIPTION QNTY UNIT COST TOTAL 1. Framing-Labor Minimum 1.00 EA @ ]56.54= 156.54 2. Remove Additional charge to remove non-strippable wallpaper 480.00 SF @ 0.24= 1]5.20 3. SeaUprime then paint the walls and ceiling(2 coats)-2 colors 704.75 SF @ 0.67= 472.18 Adjustments for Base Service Charges Adjustment Painter 93.84 Wailpaper I-Ianger I03.70 Total Adjustments for Base Service Charges: 197.54 Line Item Totals: CORT-FENSTER 941.46 Grand Total Areas: 480.00 SF Walls 224.75 SF Ceiling 704.75 SF Walls and Ceiling 224.75 SF Floor 24.97 SY Flooring 60.00 LF Floor Perimeter 0.00 SF Long Wall 0.00 SF Short Wall 60.00 LF Ceil.Perimeter 224.75 Floor Area 245.19 Total Area 480.00 Interior Wall Area 564.00 Exterior Wall Area 62.67 Exterior Perimeter of Walls 0.00 Surface Area 0.00 Number of Squares 0.00 Total Perimeter Length 0.00 Total Ridge Length 0.00 Total Hip Length CURT-FENSTER 10/21/2012 Page:2 Summary for Dwelling Line Item Total 743.92 Total Adjustments for Base Service Charges 197.54 Matl Sales Tax Reimb @ 7.875°/o x 8937 7.04 Replacement Cost Value $948.50 Net Claim $948.50 jared tix � � i I CURT-FENSTER 10/21/2012 Page:3 I �l7 •iy���#��,'t �+F ti1' r, ..`.. �J�._ r w tyi`1 �'t -+1� �y,/"� �','f����) � ` ����J ��� � ��/� j� �� ti.> . w � f i . .4 Y, �`1� � � �� y�. `� � .t.�,ij �r'a� ' � �'-,� � .. r 1 ! > �b �f*-� y l,��� - )��''�i�j �,�is .���1,' :lr 5 �J � :.'� �_.� .. �1'� ti�� Yr"� �� p�,.�.�� !✓ ��'�f �.�yY1.. y I„r,. s t. , �� }��k������l��r�"�'^# .�,.A!� I�.� .�� �;'�1`. ���I��r'y .� �a� �1� Y��r . � � ���� k ' � �'� •H /Y� l tilj/ f � ' '"'�� i. 1 ✓ � � $ + +� ) ,�.{r.L y} } _. .�Y�y - ��t v J � ' . r, s /��� R w � �,Yq J i� � v� F �' ��f��� �,���t�.r� }1 t�F}.4i r > iY�i�. �_,,.� �a s.0 .i� l.R '�< . 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