Wegwerth NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
Minnesota State Statute 466.05 states that "...every person...who claims damages from any municipality.sh�a���.s�'!b�presented to the
governing body of the municipality within 180 days after the alleged loss or injury is discovered a not' �jate� the time,place,and
circumstances thereof,and the amount of compensation or other relief dema�tt?"l� 2��3
Please complete this form in its entirety by clearly typing or printing your answer to ea��i��b�r�'�ore space is
needed,attach additional sheets. Please note that you will not be contacted by telephone to clarify answe s,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 �/�/E Middle Initial�Last Name W�'�
Company or Busrness Name
Are You an Insurance Company? Yes/�If Yes,Claim Number?
Street Address � /�f t ��U c ��
City �'� ��� State �y Zip Code S�(� �
q�'� Q �
Daytime Phone�� - Cell Phone �� 6 U' Evening Telephone(_� -
Date of Accidenb Injury or Date Discovered � �� Time �''� �m
Please state,in detail,what occurred(happened),and why you are submitting a claim.Please indicate why or h�w you
feel the ity of Saint Pa 1 or ' s e ployees,�re invo ved and/or responsible for your damages.
.-e�- y oc �
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 (,,!/� Gt�l�A '
❑ Other type of injury—please specify
In order to process your claim you 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 properly damage claims: two repair estimates if the damage exceeds$500.00; or the actual bills
andlor 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 wifiesses to the incident? Yes No Unkn n (circle)
Provide their names, addre ses and telepho m�pe s: �w n�t° L..
�}C'I�i f�Y� (��--,�/C�C� � S „T� —bS� 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 ar seeking in mpen ation or h t you ould like the City to o t resolv is claim
to your satisfaction. U C�/-P r� �. � "� �U�— ��C� �
��
Vehicle Claims—vlease comnlete this section ❑ check box if this section does not applv
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
Iniurv Claims—nlease comolete this section ❑ check box if this section does not applv
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 w s completed �
Print the Name of the Person who Completed this For . ...p �
Signature of Person Making the Claim:
Revised February 2011
January 22, 2013
RE: Water damage at 200 Bridlewood Dr., St. Paul, MN 55119
To whom it may concern:
On January 11th 2013 I received a call at about 9:45am. It was my tenant Ena, calling to
tell me the water was not working. Unfortunately, I was not able to catch her phone cali and
she left a message. I returned her call about 11:45am that day. After she left me a message at
9:45am, she then called the Water Department to see what had happened. The Water
Department informed my tenant they accidentally shut off the wrong water. The water that
needed to be shut off was 198 Bridlewood Dr.,the unit next door. While the water was off, Ena
was turning on and off the water to see if it would come back on. While doing this, and not
remembering which way was on and which way was off, she left the upstairs bathroom faucet
in the on position. Meanwhile when the water was ofF her young son was playing in the
bathroom and pulled the drain plug to the plugged position. When the Water Department
turned the water back on they never knocked on the door or informed Ena in any way to tell
her the water was back on. When the water was turned on Ena was downstairs and never
heard the water running until she saw the water leaking through the ceiling. At this point, she
ran upstairs to shut the water off in the bathroom. After this happened, I called the Water
Department and they confirmed the wrong unit was turned off. It is my belief the Water
Department is 100� liable for the damages. One,the wrong unit was accidentally shut off. If
the water was never turned off this whole incident would not have happened. Two,when the
water was turned on they never knocked to inform Ena the water was turned on and she
should check all the faucets to make sure they were in the off position. It is my understanding,
from the Water Department,the standard procedure when water is turned back on the
resident is clearly informed at that point. If the policy would have been followed the water
damage would have never occurred. I have enclosing two professional bids that were
requested of ine. See attached bids.
Sincerely,
�
Hugh rth
651-983-0404
1795 Albert St
Falcon Heights, MN 55113
�rF o�Ttos Restoration Professionals
505 Minnehaha Ave.W.
Saint Paul,MN 55103
Phone:(651)379-1990
Fax:(651)379-1991
License#BC396147
Client: Hugh Wegweth
Property: 200 Bridlewood Drive
St Paul,MN
Operator Info:
Operator: RICH
Estimator: Rich Hilmanowski Business: (651)734-5942
Business: 505 Minnehaha Ave W E-mail: rhilmanowski@restpro.com
St Paul,MN 55103
Type of Estimate: Water Damage
Date Entered: 1/17/2013 Date Assigned:
Price List: NINMN7X JAN13
Labor Efficiency: Restoration/Service/Remodel
Estimate: WEGWATH
OS-0572043
This is an estimate for the scope of work as our estimator viewed it at the time.If scope changes need to be made,the estimator
will revise as soon as he/she is made aware of it.This estimate is good for 30 days.Pricing changes may occur after 30days.If
this estimate is provided to an insurance company,there may need to be some changes,per discussion with the adjuster.The
estimator will make the adjustments as needed.Thank you,and as always,Restoration Professionals appreciates working with
you.
�rFl� Restoration Professionals
505 Minnehaha Ave.W.
Saint Paul,MN 55103
Phone:(651)379-1990
Fax:(651)379-1991
License#BC396147
WEGWATH
Main Level
�-�o•� Bathroom Height:8'
T g j� � 245.24 SF Walls 53.28 SF Ceiling
� �
1 "5•a,j'�` ^ °' 298.53 SF Walls&Ceiling 53.28 SF Floor
i 2, I 5.92 SY Flooring 30.24 LF Floor Perimeter
�r r t•
1 32.74 LF Ceil.Perimeter
Door 2'6" X 6'8" Opens into Exterior
DESCRIPTION QNTY REMOVE REPLACE TOTAL
1. Detach&Reset Sink faucet-Bathroom 1.00 EA 0.00 0.00 100.25
2. Vanity top-Detach and reset 4.00 LF 0.00 16.64 66.56
3. R&R Vanity 4.00 LF 6.59 127.27 535.44
4. R&R Vinyl floor covering(sheet goods) 53.28 SF 0.81 3.15 210.99
5. R&R Underlayment- 1/4" 53.28 SF 1.02 1.25 120.95
lauan/mahogany plywood
6. Baseboard-Detach and reset 30.24 LF 0.00 132 39.92
7. Final cleaning-construction-Residential 53.28 SF 0.00 0.19 10.12
Totals: Bathroom 1,084.23
•'r°'s Linen Closet Height:8'
S'4"-�
T T 111.82 SF Walls 9.97 SF Ceiling
� �� N 121.79 SF Walls&Ceiling 9.97 SF Floor
~_5�,_� 1.11 SY Flooring 13.98 LF Floor Perimeter
13.98 LF Ceil.Perimeter
DESCRIPTION QNTY REMOVE REPLACE TOTAL
8. R&R Vinyl floor covering(sheet goods) 9.97 SF 0.81 3.15 39.49
9. R&R Underlayment- 1/4" 9.97 SF 1.02 1.25 22.63
lauan/mahogany plywood
10. Final cleaning-construction- 9.97 SF 0.00 0.19 1.89
Residential
WEGWATH 1/18/2013 Page:2
�� Restoration Professionals
505 Minnehaha Ave.W.
Saint Paul,MN 55103
Phone:(651)379-1990
Fax:(651)379-1991
License#BC396147
CONTINUED-Linen Closet
DESCRIPTION QNTY REMOVE REPLACE TOTAL
Totals: Linen Closet 64.01
Total:Main Level 1,148.24
Lower Level
1~-~"'T Family Room Height:8'
�,. ,
: ; '"' i
j �� 854.92 SF Walls 340.15 SF Ceiling
r.r
1 ._� g ; 1,195.07 SF Walls&Ceiling 340.15 SF Floor
1 "-+T 37.79 SY Flooring 106.86 LF Floor Perimeter
1 �-- r..
w � 106.86 LF Ceil.Perimeter
1
DESCRIPTION QNTY REMOVE REPLACE TOTAL
i l. Floor protection-self-adhesive plastic 340.15 SF 0.00 0.39 132.66
film
12. Tear out wet drywall,cleanup,bag for 64.00 SF 0.64 0.00 40.96
disposal
13. Remove Acoustic ceiling(popcorn) 276.15 SF 0.40 0.00 110.46
te�rture
14. (Material Only)5/8"drywall-hung, 64.00 SF 0.00 0.42 26.88
taped,floated,ready for paint
15. Drywall-Labor Minimum 1.00 EA 0.00 246.09 246.09
Labor to install 64 sq ft 5/8"drywall
16. Drywall-General Laborer-per hour 4.00 HR 0.00 39.22 156.88
Labor to pick up materials and to blend with existing drywall
17. Mask wall-plastic,paper,tape(per LF) 106.86 LF 0.00 0.80 85.49
18. Seal the ceiling w/PVA primer-one 340.15 SF 0.00 0.34 115.65
coat
19. Acoustic ceiling(popcorn)te�cture 340.15 SF 0.00 0.70 238.11
20. Final cleaning-construction- 340.15 SF 0.00 0.19 64.63
Residential
Totals: Family Room 1,217.81
Total:Lower Level ��21�•g�
WEGWATN 1/18/2013 Page:3
�r� Restoration Professionals
505 Minnehaha Ave.W.
Saint Paul,MN 55103
Phone:(651)379-1990
Fax:(651)379-1991
License#BC396147
General Conditions
DESCRIPTION QNTY REMOVE REPLACE TOTAL
21. Haul debris-per pickup truck load- 1.00 EA 123.09 0.00 123.09
including dump fees
Totals: General Conditions 123.09
Line Item Subtotals:WEGWATH 2,489.14
Adjustments for Base Service Charges Adjustment
Carpenter-Finish,Trim/Cabinet 12g•28
Cleaning Technician 60.14
Cleaning Remediation Technician 87.64
Drywall Installer/Finisher 2�g•52
Flooring Installer 12930
Plumber 222.04
Painter 93.64
Tile/Cultured Mazble Installer 177.70
Total Adjustments for Base Service Charges: 1,117.26
Line Item Totals: WEGWATH 3,606.40
Grand Total Areas:
1,211.98 SF Walls 403.41 SF Ceiling 1,61539 SF Walls and Ceiling
403.41 SF Floor 44.82 SY Flooring 151.08 LF Floor Perimeter
0.00 SF Long Wall 0.00 SF Short Wall 153.58 LF Ceil.Perimeter
403.41 Floor Area 453.27 Total Area 1,211.98 Interior Wall Area
1,287.77 Exterior Wall Area 144.94 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
WEGWATH 1/18/2013 Page:4
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.., Servpro Of Cottage Grove/Woodbury
Rn 6 wdr�C4wxryr 6 Renuofan'
Franchise#9749
680 Commerce Dr,Suite 220
Woodbury,MN 55125
651-779-1000/651-773-8888 Fax
j_sadvik@comcast.net
Client: Hugh Wentworth Home: (651)983-0404
Properiy: 200 Bridlewood Dr
St.Paul,MN 55119
Operator Info:
Operator: JOE
Estimator: Terry
Type of Estimate:
Date Entered: 1/22/2013 Date Assigned:
Price List: MNMN7X JAN13
Labor Efficiency: Restoration/Service/Remodel
Estimate: WENTWORTH HiJGH
.., Servpro Of Cottage Grove/Woodbury
Rr�6W�CLor�up6RWVO�m�
Franchise#9749
680 Commerce Dr,Suite 220
Woodbury,MN 55125
651-779-1000/651-773-8888 Fax
j_sadvik@comcast.net
WENTWORTH HUGH
Main Level
Main Level
DESCRIPTION QNTY REMOVE REPLACE TOTAL
1. Haul debris-per pickup truck load- 1.00 EA 123.09 0.00 123.09
including dump fees
Total: Main Level 123.09
�--•--� Height:8'
1 ,., j Living Room
'r"" 1 � °'-'1 857.33 SF Walls 366.50 SF Ceiling
..-,�,
'I ' j'-;;-"r • • 1,223.83 SF Walls&Ceiling 366.50 SF Floor
I • 1 ' • ' 1 40.72 SY Flooring 107.17 LF Floor Perimeter
� ,� i �-,.�
,_..._., 107.17 LF Ceil.Perimeter
DESCRIPTION QNTY REMOVE REPLACE TOTAL
2. Mask per square foot for drywall or 857.33 SF 0.00 0.14 120.03
plaster work
3. Floor protection-plastic and tape- 10 366.50 SF 0.00 0.21 76.97
mil
4. Tear out wet drywall,cleanup,bag for 32.00 SF 0.64 0.00 20.48
disposal
5. Drywall Repair-Minimum Charge- 1.00 EA 0.00 258.08 258.08
Labor and Material
6. R&R Acoustic ceiling(popcorn)texture 366.50 SF 0.40 0.70 403.15
7. Texture drywall-smooth/skim coat 366.50 SF 0.00 0.78 285.87
8. SeaUprime the ceiling-one coat-low or 366.50 SF 0.00 0.42 153.93
no VOC
9. Contents-move out then reset 1.00 EA 0.00 49.43 49.43
Totals: Living Room 1,367.94
Total:Main Level 1,491.03
Upper Level
WENTWORTI-I HUGH 1/22/2013 Page:2
.., Servpro Of Cottage Grove/Woodbury
Fn i MV w.Oox9 6 tewaf an�
Franchise#9749
680 Commerce Dr,Suite 220
Woodbury,MN 55125
651-779-1000/651-773-8888 Fax
j_sadvik@comcast.net
�rs•--� Bathroom Height:8'
, T Z� � 185.85 SF Walls 43.02 SF Ceiling
�'Q �� � 228.88 SF Walls&Ceiling 43.02 SF Floor
` f �r -;� j 4.78 SY Flooring 23.23 LF Floor Perimeter
y 23.23 LF Ceil.Perimeter
t'1• T 2'
Missing Wall 4' 11"X 8' Opens into TUB
DESCRIPTION QNTY REMOVE REPLACE TOTAL
10. Toilet-Detach&reset 1.00 EA 0.00 201.96 201.96
11. R&R Vanity 4.00 LF 6.59 127.27 535.44
12. Vanity top-Detach and reset 4.00 LF 0.00 16.64 66.56
13. R&R Baseboard-3 1/4"stain grade 16.00 LF 0.40 3.23 58.08
14. Stain&finish baseboard 16.00 LF 0.00 0.94 15.04
15. Remove Tear out vinyl&underlayment 43.02 SF 1.29 0.00 55.50
16. Underlayment- 1/4"hardboard 43.02 SF 0.00 1.41 60.66
17. Vinyl floor covering(sheet goods) 49.48 SF 0.00 3.15 155.86
18. R&R Carpet-metal transition strip 6.00 LF 0.67 2.94 21.66
19. Dehumidifier(per 24 hour period)- 2.00 EA 0.00 71.00 142.00
Large-No monitoring
20. Air mover axial fan(per 24 hour period) 2.00 EA 0.00 29.01 58.02
-No monitoring
Totals: Bathroom 1,370.78
Total:Upper Level 1,370.78
Line Item Subtotals:WENTWORTH_HUGH 2,861.81
Adjustments for Base Service Charges Adjustment
Carpenter-Finish,Trim/Cabinet 12g'2g
Cleaning Remediation Technician 87.64
Drywall Installer/Finisher 218.52
Flooring Installer 129.30
General Laborer 39.22
Plumber
222.04
93.64
Painter
Tile/Cultured Marble Installer 177.70
WENTWORTH HUGH 1/22/2013 Page:3
�r Servpro Of Cottage Grove/Woodbury
he8 MVr-O�w�up{�pu�m�
Franchise#9749
680 Commerce Dr,Suite 220
Woodbury,MN 55125
651-779-1000/651-773-8888 Fa�c
j_sadvik@comcast.net
Adjustments for Base Service Charges Adjustment
Total Adjustments for Base Service Charges: 1,096.34
Line Item Totals: WENTWORTH HUGH 3,958.15
Grand Total Areas:
1,117.33 SF Walls 420.22 SF Ceiling 1,537.56 SF Walls and Ceiling
420.22 SF Floor 46.69 SY Flooring 139.67 LF Floor Perimeter
0.00 SF Long Wall 0.00 SF Short Wall 139.67 LF Ceil.Perimeter
420.22 Floor Area 467.67 Total Area 1,117.33 Interior Wall Area
1,305.00 Exterior Wall Area 145.00 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
WENTWORTH HIJGH 1/22/2013 Page:4
.�r Servpro Of Cottage Grove/Woodbury
�..�...�.,.�-
Franchise#9749
680 Commerce Dr,Suite 220
Woodbury,MN 55125
651-779-1000/651-773-8888 Fax
j_sadvi k@com cast.net
Summary
Line Item Total 2,861.81
Total Adjustments for Base Service Chazges 1,096.34
Matl Sales Taac Reimb @ 7.625% x 804.90 61.37
4,019.52
Overhead @ 10.0% x 4,019.52 401.95
Profit @ 10.0% x 4,019.52 401.95
Cleaning Sales Tax @ 7.625% x 240.02 18.30
Replacement Cost Value $4,841.72
Net Claim $4,841.72
Terry
j
i
WENTWORTH HLJGH 1/22/2013 Page:S