Woods, Access Communications Inc ti��;���EC�
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NOTICE OF CLAIM FORM to the City of Saint Pa,���;Minnesota
Minnesota State Statute 466.05 states that "...every person...who claims damages 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 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 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
First Name Roni Middle Initial K Last Name Woods
Company or Business Name Access Communications,Inc.
Are You an Insurance Company? Yes/No If Yes, Claim Number? No
Street Address 5005 Cheshire Parkwav Suite 1
City Plvmouth _State MN _Zip Code 55446
Daytime Phone (763)545-9998 Cell Phone n/a - Evening Telephone n/a -
Date of Accident/Injury or Date Discovered 12-5-2012 Time lOAM am/pm
Please state, in detail,what occurred(happened), and why you are submitting a claim. Please indicate why ar how you �
feel the City of Saint Paul or its employees are involved and/or responsible for your damages.
Curt Wolf with the Citv ofNSt Paul Water called the of�ce and renorted thev had broken the duct at
Geneva & Midvale in Maplewood The conduit was exposed on the west side of the duct path runninQ
throu�h the east side of the excavation hole The machine operator was taking a scoon with the bucket
above the exposed conduit The bucket cauQht on tree roots interhvined around the conduit thus vullan,�
stretchin�and breakinQ the conduit The bucket did not come in contact with the conduit. The fiber �
appears to be undamaPed(no scuff marks or scravs). The locate marks were and sti[l are�ood.
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
X Other type of property damage—please specify investiQate and renair of duct nath I
0 Other type of injury—please specify
In order to process your claim���u need to include copies of all applicable 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
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
• Photographs are always welcome to document and support your claim but will not be returned.
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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? Yes No Unknown (circle)
Provide their names,addresses and telephone numbers: Curt Wolf and crew—Citv of N S� Paul ReQional Water
651-775-1782
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.
Geneva&Midvale Place Maplewood MN
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. $777.74
Vehicle Claims— lease com lete this section heck box if this section does not a 1
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
Injurv Claims please complete this section �']check box if this section does not apnlv
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 6 .
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 1-3-2013
Print the Name of the Person who Completed this Form: ���' ��/ ���j�� ��nS
� � '�--1
Signature of Person Making the Claim: �u--� �i'L���7�'
Revised February 2011
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, , Invoice
_ � Commun�cat�ons Invoice Number:
vr�� IIICO/pOl�t� 24 0 6 6
Invoice Date:
5005 Cheshire Pkwy N. Suite 1, Plymouth,Mn 55446-4108 Dec 13, 2 012
763-545-9998 Fax 763-545-1494 Page:
1
Sold To:
St. Paul Regional Water
1900 Rice St .
Roseville, MN 55113
Customer ID Customer PO Customer Contact M
St Paul Water Ticket#123340858
Sales Re ID Shippinq Method Payment Terms Due Date
Woods Net 30 Days 1/12/13
Quantity Item Description Unit Price Extension
3 .50 12.5.12 Locator Labor Standard Rate 80.00 280.00
1.00 12 .5.12 Trip Charge 75.00 75.00
2.00 Miscellaneous Supplies 15.00 30.00
2.00 12.5.12 Fiber Technician Labor 120.00 240.00
Standard Rate
1.00 12.5.12 Trip Charge 75.00 75.00
2 .00 3M 3939 Duct Tape - 2" x 60 Yards 9.10 18.20
5.00 CRS P15F 1.5" Split Duct Conduit 7.00 35.00
1.00 CRS P125F 1.25" Split Duct Conduit 6.83 6.83
1.00 Miscellaneous Supplies 15.00 15.00
Fiber hit at Geneva & Midvale Place,
Maplewood, MN.
Contractor called and reported a
damaged to fiber and duct.
Dispatched a locator to site to
investigate and document damage.
Dispatched a fiber technician to site
to investigate further in vaults and
repair damage.
Investigation found duct was damaged
but not fiber. Repaired duct with
SUbtOt81 Continued
Sales Tax Continued
Freight Continued
Total Invoice Amouni Continued
Payment Received Continued
Check No:
TOTAL Continued
Terms 30 days. Finance charges of 1.5� per month will accrue on past due accounts.
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Invoice
� �'O/N/IIIUI%Cdt/OBS Invoice Number:
�3�vr�7`'� lnco�porated 240 66
Invoice Date:
5005 Cheshire Pkwy N. Suite 1, Plymouth,Mn 55446-4108 Dec 13, 2012
763-545-9998 Fax 763-545-1494 Page:
2
Sold To:
St. Paul Regional Water
1900 Rice St .
Roseville, MN 55113
Customer ID Customer PO Customer Contact
St Paul Water Ticket#123�40858
Sales Re ID Shippinq Method Payment Terms Due Date
Woods Net 30 Days 1/12/13
Quantity Item Description Unit Price Extension
split duct and tape.
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Subtotal 775.03
Sales Tax
Freight 2 .40
Total Invoice Amount 777.43
Check No:
Payment Received o.o0
TOTAL ���•43
Terms 30 days. Finance charges of 1.5$ per month will accrue on past due accounts.
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Fiber Hit Process & Procedure
Date & Time of Hit Re orted B
12-5-12 10:30 AM cu►� woif
Go her One Ticket# Affected Customer
Ticket Number: 123340858 ACCOM No. 58 No. St. Paul
Police Re ort Y/N ? A enc & Re ort#
N
Photos Taken Y/N ? Photos Taken B
Y Aaron Mehrman
Res onsible Pa In���c�n
Name: Curt Wolf
Com�any Name: ST PAUL REGIONAL WATER
Phone #: 651-775-1782
Alt. Phone #: 651-266-6868 EXT: 2
Fax#: NA
Insurance Com an : Cit of St. Paul 1900 Rice St., Roseville, MN 55113
Insurance Polic #:
Insurance Phone #:
Other Info:
Location of Hit (Address, Intersection, etc.) M
1059 Century Ave North. Century Ave and Midvale PI
:�.�Descrrp�ion� `'� ident � �
Per Curt Wolf with the City of N St Paul Water. The conduit was exposed on the west
side of the duct path running through the east side of the excavation hole. The machine
operator was taking a scoop with the bucket above the exposed conduit. The bucket
caught on tree roots intertwined around the conduit thus pulling stretching and breaking
the conduit. The bucket did not come in contact with the conduit. The fiber appears to be
undamaged (no scuff marks or scraps). The locate marks were and still are good.
Original Message-----
From: gsoctransition@korpartners.com [mailto:gsoctransition@korpartners.com]
Sent: Thursday, November 29, 2012 11:21 AM
To: acccom0l�access-com.net
Subject: NORMAL GeoCall Locate Information - 123340858
Gopher State One Call Locate Request
Ticket Number: 123340858 Old Ticket:
By: DI M Source: EMAIL
Type: NORMAL Date: 11/29/2012 11:20:26 AM
Send To: ACCCOM58 Sequence: 8
Company Information
----------------------------------------------------------------------------
ST PAUL REGIONAL WATER Type: GOVERNMENT
1900 RICE ST
ROSEVILLE, MN 55113
Caller: JACKIE CAREY Caller Phone: (651) 266-6874 �
Contact: CURT WOLF Contact Phone: (651) 775-1782
Company Phone: (651) 266-6874 Company Fax:
Company Email: JACKIE.CAREY�CI.STPAUL.MN.US
Work Information
----------------------------------------------------------------------------
State: MN Work Date: 12/03/2012 11:30:07 AM
County: RAMSEY Done For: ST PAUL REGIONAL W
Place: MAPLEWOOD
Street: 0 GENEVA AVE N
Intersection: MIDVALE PL
Type of Work: OTHER - SEE REMARKS
Explosives: No Tunnel/Bore: No
Right of Way: Yes Duration: 1 DAYS
Remarks
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OTHER WORK TYPE DESCRIPTION: REPLACE FIRE HYDRANT
MARKING INSTRUCTIONS: FROM THE INTERSECTION OF GENEVA AVE N AND MIDVALE PL PROCEED
APPROXIMATELY 410 FEET NORTH ON GENEVA TO THE HYDRANT LOCATED ON THE
WEST SIDE OF THE STREET AND MARK A 40 FOOT RADIUS TO REPLACE THE FIRE
HYDRANT
DRIVING DIRECTIONS:
ALT CONTACT: 1204482-01 - (651) 266-6874
LAT/LONG SW: 44.971379 -92.985258 k
LAT/LONG NE: 44.973264 -92.984575
ORIGINAL FILE: KOR_2012112900544.XML
Members
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Code Name Phone Number
----------------------------------------------------------------------------
ACCCOM58 ACCESS COMMUNICATION TECH 7635459998 �
CMPLWD01 CITY OF MAPLEWOOD 6512492430
COMCST01 COMCAST (612) 522-8141
MNSDOT01 DEPARTMENT OF TRANSPORTATION (651) 366-5750
QLNMNI4 QWEST (800) 283-4237
STPLWT01 ST. PAUL WATER UTILITY 6512666868
XCEL06 XCEL ENERGY (651) 229-2427
Location
----------------------------------------------------------------------------
Latitude: 44.9750631555514 Longitude: -92.9856241869303
Second Latitude: 44.9719230538498 Second Longitude: -92.9845774863631
T29NR21WS30QNW T29NR22WS25QNE
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