McConnon T NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
Minnesota State Statute 466.05 states that"...every person...who daims damnges from any municipatity...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 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 aaswers,so provide as
much information as necessary to egplain 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 sometWng dces 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_����I Vl Middle Initial � Last Name/ � �L�0 P�-��'1
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Company or Business Name N �t �(��. (��(.Z�yt.�.�-�
Are You an Insurance Company? Yes No ff Yes,Claim Number?
Street Address � 1 ��' �i-a-'�-�--�-�- ���-
c i ;�` �/� (�
City J� • G� State �'��U Zip Code,;,,,-�-f—
Daytime Phone(���O-�Cell Phone (a 5 )�S7-�C',5 Evening Telephone(�)�- 3� �
Date of Accidend Injury or Date Discovered � (1 �Z- Time '�5 am/pm
Please state,in detail,what occurred(happened),and why you are submitting a claim.Please indicate why or how you
fee the City of Saint Paul or its employees are involved and/or responsible for your damages.
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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
�Other type of property damage-please specify t���� -{y .t �,C,��(,e,of�A-eYS
Other type of injury-please specify
In order to process your claim vou need to include conies of all anulicable 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 retumed 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
� Other property damage claims: two repair estimates if the damage exceeds$500.00;or the actual bills
and/or receipts for the repairs;detailed list of damaged items
O Injury claims: medical bills,receipts
�Ph�ot��ph�,.,are always welcome to document and support your claim but will not be returned.
( ���1
Page 1 of 2-Please complete and return both pages of Claim Form
Failure to complete and return both pages will result in delay in the handling�your clairu.
All Claims—nlease complete this section
Were there witnesses to the incident? Yes N , Unlmown (circle)
Provi e their names,addresses and telephone numbers: � �'.�J�t �7'�
5�, �Qu.�.2 rv�,�( �5 i- t��t y- 4�$ i�
Were the police or law enforcement called� es , No Unlrnown (circle) SC,�✓� M01'I C!�-
If yes,what department or agency?��-• ��,t,�. �i�_��,�� Case#or report# �'�"{ � .
i re�
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�diagram.
� r ; ����r5 � l�.ern e. � f l y� '�,c�?.eJ� �v C � �t� •_cu,� J'VL�V �i��/D��
Please indicate the a�nount you are eeking in compensarion or what you ould lil�e the City to o to reso ve 's claim
to our sa' factiorr�" . 5 i � C�� —F" �� • d
�
Vehicle Claims—please complete this section ❑check box if this section does not annlv
Your V�hicle: Year Make Model
N t� License Plate Number State Color
Registered Owner
Driver of Vehicle
Area Damaged
City Vehicle: Year Make Model
License Plate Number State Color
N�� Driver of Vehicle(City Employee's Name)
Area Damaged
Injurv Claims—please comrplete tt►is 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
'�Check here if you are attaching more pages to this claim form. Number of ad iNonal pages `�
. �� ���( G�-r"�: )Z ���"��}'✓�p�S (!� `� ���'�-�d'
By stgning th�s form,you are stat�ing 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 ��T�� �7i
Print the Name of the Person who Completed this Form: T�e,b� ti h i ►'�e �b �`v1���
Signature of Person Making the Claim:�,[�^ //' "( ������
Revised February 2011
11/24/12
City Clerk
City of Saint Paul, MN
Kevin and Theresa McConnon
1744 Laurel Ave
St. Paul, MN 55104
Re: claim form
To whom it may concern:
On Tuesday 9/11/12 at approximately 4:45 pm, the St. Paul Fire Department dispatched fire trucks to
our home located at 1744 Laurel Ave in St. Paul because they thought there was a fire at our residence.
The fire was not at our residence but was actually at 1744 Ashland, which is one block over from our
home. Our neighbors(Ginney DeLuca 651-644-8814) witnessed firemen striking our front door several
times with a tool. When this door did not open, the firemen then went to our side door. They forced
open the side storm door and then broke the window of the interior door. They attempted to pry open
the side interior door but were then informed by dispatch that they were at the wrong house. They
were directed to 1744 Ashland and immediately left. Shortly thereafter a repairman arrived, who said
he was directed to our house by the fire department. He replaced our side door broken window with a
piece of wood that he drilled into the door with 9 screws that protrude through the door and told us this
was done to "secure the home". This piece of wood is still in place on our door. A fireman by the name
of Sean Moriary (651-485-5588) came to our home immediately following this incident and apologized
for the damages to our home,stating it was a mistake and that they had the wrong house. He gave us a
business card with the fire department assistant fire chieYs phone number, Jim Smith, and asked us to
contact the assistant chief the next day, which we did. A fire inspector came to our home on Thursday
9/13/12 and took pictures of the damages to the doors. He said he would e-mail the pictures to us, but I
never received them.
When the fireman struck the front door they scraped off some of the finish on the door and broke a
piece of the molding. They also cracked the door in several places including the face of the door and the
area where the handle on the door engages the door jam. The door no longer seals tightly as it had ;
previous to this incident. Even in the locked position it pulls forward before the lock engages. The front
door is a beautiful wooden door which would be extremely expensive to replace.
When the firemen forced open the wooden side storm door, they cracked the bottom panel of the
storm door and damaged the footing area below the storm door and the interior door. They broke the
glass window on the interior door, cracked the face of the interior door, cracked the area where the
handle engages the door jam on the interior door and damaged the deadbolt area on the interior door. �
Due to the damage to the side doors we have attached 2 estimates for the purpose of replacing the '
Storm and Interior doors on the side of the house. Regarding the front door, we received 2 opinions ,
from the same companies in which we received the estimates for the side doors indicating that it would '
cost at least $500 to repair the molding and the door jam on the front door. Replacing the whole door
would be too expensive and these repairs could return the door to nearfy same the working condition.
We are also requesting $34.99 for the cost of replacing a new 30 Ib bag of dog food which was right
below the window of the side door that was broken. The broken glass from the window ended falling
into the bag of dog food and it had to be replaced.
Attached are pictures of the damages to our front and side doors with this letter.
Please contact us if you have questions.
Sincerely,
r �j�►�
1��� � �
Kevin McConnon
651-646-3379 (home)
651-357-7805(cell)
651-266-2359(work)
I
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� BEIS SEL State license#6453
WINDOW<SIDING Teleahone:(6511451-6835
1635 Oakdale Avenue,West S�Paul,Minnesota 55118 � Faz:(651)451-0531
PROPOSAL SUBMITTiED TO PHONE DATE
�v � �v � o �•vo�/ �s 3 5�- ��'as /D-// -� 12
STREET JOB NAME
� � yy �.�-� � �� � �
CIN,STATE&ZIP CADE JOB LOCATION
S 1• r9-��, it/ . .��51 D
WE PROPOSE TO FURNISH ALL LAB�R,MATERIALS AND EQUIPMENT NECESSARY TO COMPLETE THE WORK AS FOLLOWS:
C c�5 / OM L3 c�,�LD �- /NS I ��! 1 5 l ��L �' N/R� � �U �
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WE AGREE TO DO ABOVE DESCRIBED WORK FOR THE SUM OF$ TO BE PAID AS FOLLOWS
VERBAL AGREEMENTS NOT BINDING-ALL ADDITIONAL WORK AND AGREE-
MENTS MUST BE SHOWN IN WRITING. ALL ORDERS ACCEPTED BY US WITH
THE UNDERSTANDING THAT WE ARE NOT TO BE HELD LIABLE FOR CAUSES
BEYOND OUR CONTROL THIS PROPOSAL SUBJECT TO ACCEPTANCE WITHIN AUTHORIZ IGNATURE
30 DAYS. BALANCE OF JOB MINUS DOWN PAYMENT DUE ON COMPLETION.
We are required by law to provide you with the following notice regarding the rights of persons fumishing labor and materials:
(A) My person or company supplying labor or materials for this improvement to your property may file a lien against your properry if that person
or company is not paid for the contnbutions.
(B) Under Minnesota law,you have the right to pay persons who supplied labor or materials for this improvement directly and deduct this amount
from our contract price,or withhold the amounts due them from us until 120 days after completion of the improvement unless we give you a
lien waiver signed by persons who supplied any labor or material for the improvement and who gave you timely notice.
I HAVE READ THE ABOVE AND ACCEPT THE TERMS AND CONDITIONS OF THIS CONTRACT.
SIGNATURE DATE
White- Beissel Yellow- Customer READ REVERSE SIDE
� TERMS AND CONDITIONS
I
�� 1. THIS CONTRACT IS SUBJECT TO APPROVAL AND ACCEPTANCE BY THE GENERAL MANAGER
OF BEISSEL WINDOW& SIDING CO. (HEREINAFTER REFERRED TO AS BEISSEL).
2. PURCHASER SHALL PAY ALL SR'�.ES AND USE TAXE� ND THE COST OF ANY CHA�-aGES OR
VARIANCES REQUIRED �Y BUILDING CODE INCLUDIf:a VENTILATION SYSTEM COMPLIANCE,
EGRESS WINDOW REQUIREMENTS AND SMOKE DETECTORS.
3. ALL SURPLUS MATERIALS REMAIN THE PROPERTY OF BEISSEL.
4. BEISSEL WILL CARRY THE LICENSES AND BONDS REQUIRED BY THE BUILDING CODE AND
ZONING ORDINANCES.
5. BEISSEL WILL CARRY WORKERS' COMPENSATION AND PUBLIC LIABILITY INSURANCE
PROTECTION.
6. PURCHASER'S INSURANCE SHALL BE PRIMARILY LIABLE FOR LOSS OF, OR DAMAGE TO
MATERIALS ON JOBSITE, INCLUDfNG WITHOUT LIMITATION BY THEFT, VANDALISM, WIND,
RAIN, FIRE AND NEGLIGENT ACTS. �
7. THIS CONTRACT IS A COMPLETE AND EXCLUSIVE STATEMENT OF THE TERMS OF THE
AGREEMENT OF THE PARTIES HERETO. THERE ARE NO UNDERSTANDINGS OR
REPRESENTATIONS EXCEPT AS STATED HEREIN.
8. ALL WORK INCLUDED IN THIS CONTRACTASSUMES EXISTING MECHANICAL AND
ELECTRICAL EQUIPMENT IS WITHIN PRESENT CODE STANDARDS. IF UPDATING IS
REQUIRED, THIS COST IS TO BE AN ADDITIONAL CHARGE. ALSO, BEISSEL IS NOT
RESPONSIBLE FOR ANY DAMAGE TO INTERIOR AND EXTERIOR FINISHES THAT MAY
OCCUR DURING THE INSTALLATION PROCESS.
9. THERE ARE OCCASIONS WHEN OUR SOURCES OF SUPPLY CANNOT SATISFY DEMAND
ON SPECIFIC ITEMS. CONSEQUENTLY, WE MUST RESERVE THE RIGHT TO CHANGE
SPECIFICATIONS FOR AN EQUAL OR BETTER SUBSTITUTE. AQDITIONALLY, BEISSEL
IS NOT RESPONSIBLE FOR VENDOR DELAYS.
10. BEISSEL CALLS THE PURCHASER'S ATTENTION TO THE LIMITATIONS OF MATCHING
COLORS AND TEXTURES OF OUR PRODUCT LINES. EXACT DUPLICATION IS NOT
PROMISED.
11. ALL BALANCES ARE DUE IN FULL UPON COMPLETION UNLESS WORK IS SUBSTANTIALLY
COMPLETED THEN 90% OF THE BALANCE DUE IS REQUIRED. A MECHANIC'S LIEN WILL
AUTOMATICALLY BE FILED ON ANY ACCOUNTS NOT PAID WITHIN 30 DAYS OF INVOICE.
PURCHASER WILL BE LIABLE FOR ALL ATTORNEY'S FEES, COSTS AND EXPENSES OF
COLLECTION INCLUDING LIEN FILINGS, AS WELL AS LEGAL INTEREST IN THE AMOUNT
OF .667% PER MONTH FROM THE DATE THE ORIGINAL AMOUNT WAS DUE.
REQUIRED NOTICE TO PURCHASER
A) DO NOT SIGN THIS BEFORE YOU READ THE WRITING ON THE REVERSE SIDE, EVEN IF
OTHERWISE ADVISED.
B) DO NOT SIGN THIS IF IT CONTAINS ANY BLANK SPACES.
C) YOU ARE ENTITLED TO AN EXACT COPY OF ANY AGREEMENT YOU SIGN. YOU, THE
PURCHASER, MAY CANCEL THIS PURCHASE AT ANY TIME PRIOR TO MIDNIGHT OF TI=1E
THIRD BUSINESS DAY AFTER THE DATE OF THIS PURCHASE.
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ENTRY DOOR PROPOSAL
LINDUS CONSTRUCTION, INC.
Minnesota License No. 7644
879 U.S. Hwy 63 Baldwin, WI 54002
1-800-873-1451 715-684-4647 Fax: 715-684-3859
PROPOSAL SUBMITTED TO(BUYER) HOME PHONE CELL PHONE DATE OF PROPOSAL
Kevin McConnon 651-646-3379 651-357-7805 10/16/2012
STREET JOB NAME
1744 Laurel Ave
CITY,STATE AND ZIP CODE JOB LOCATION
St. Paul, MN 55104
FAX# E-MAIL 10B PHONE
We Propose hereby to furnish all material and labor, skill and equipment ("Work")to complete the Scope of
Work identified below in exchange for the sum ("Contract Price") of:
Total $3,900.00
Payment shall be made as follows: 1/3 Down $1,300.00
1/3 Down, 1/3 Start, 1/3 Upon Substantial Completion 1/3 Start $1,300.00
Upon substantial completion Buyer may withhold 150%of the cost galance $1,300.00
of any incomplete Work until the Work is finally completed.
This proposal will expire if not accepted within 30 days. LINDUS CONSTRUCTION, INC.
Make all checks payable to Lindus Construction,Inc. Authorized
Signature DOUG MCCOLGAN 612-799-1333
The following Scope of Work,written wamanties and disclosures are included:
1) Lindus Lifetime Workmanship Limited Warranty
2) MN Statutes Chapter 327A Warranty
3) Builders Association of the Twin Cities Minimum Performance Standards
" Pro-Via Entry Door Project"
— -Lindus to remove & install (1�new entry door system c4� (1) new storm door
- Door will be installed into the rough openings, re-insulated and exterior brick mold wrapped/cladded in
smooth aluminum. New interior trim stained or painted;New Schlage hardware included
Front Entrv Door Ontion 1: ProVia Legacy Steel Door(Hardware& Installation included):
Door Style: 20 Gauge Smooth Steel; (#206DC) Finished White in& out
Front Storm Door Option: Provia (Hardware & installation included)
Door style: Deluxe#379 Self-Storing '/2 view glass. Color: T.B.D
- *Egisting door is below grade of sidewalk; Custom Height for both doors is required in order to
install doors properly.
- Lead test is required by Minnesota if home was built before 1978; if positive additional $250.00 will be
added to the final balance due for proper removal &disposal of existing windows ect...
- Permit may be required by St Paul; cost of permit to be added to final invoice to insure accuracy