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Kvasnik , , ��;�C�I�./�� q�r � � �A � R 0 2013 NOTICE OF CLAIM FORM to the Cit of Saint Paul, Mi�nneso�a R� Y Minnesota State Statute 466.05 states that"...every person.,.who claims damages from any municipaliry...sha[1 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 ttiis 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 tetephone 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 FirstName ��'� MiddleInitial /f LastName ��"�''\ �IFi��/�1��'-5 ¢ Company or Business Name ��'`}s``�(r �ifo�'E�T�r�,S �. L�.-�-. Z��U��'S if�-eX�`� -S�'- ,��.�_ SS�tJ L� Are You an Insurance Company? Yes/(�o If Yes,Claim Number? �- Street Address ��5`-1-��SZP .SsZL$.�/h� - ��Z?R.Q�.L.. o��/�Dt��'n'� �� Qv2s ��s�1, - City s� ��- State�N+`� Zip Code S S/l/� Daytime Phone(�5� )��` -O y7b� Cell Phone(� )�� - °��3 Evening Telephone(��)Ssi_ 2�?� Date of AccidenU Injury or Date Discovered �l� r�3 Time �•`�°� am� Please state,in detail,what occurred(happened),and why you are submitting a claim.Please indicate why or how you feei the City o:Saint Paul or its employees are in��lvetl and/or res onsiblc for our damages. ,.'Le� � -t-�-�r�H��,� Gy-�—r 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 ❑M�vehicle was wronbfully towed an�,�or ticketed ❑I was injured on City property � J�Other type of property damage-please specify ��' `�ascl dW2-- {"��ss �kF�.ow��f f ss�-�sS� ,�Q��.�,,_Q ❑ Other type of injury-please specify In order to process your claim vou need to include copies of all applicable doeuments. 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: ]egible copies of any ticket issued and a copy of the impound lot receipt ,IB�Other property damage claims: two repair estimates if the damage exceeds$500.00;or the actur__ al b_lls_ C�� and/or receipts for the repairs;detailed list of damaged items C 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? Yes No Unknown (circle) Provide their names, addresses and tele hone numbers: �i��-�� 4 ��S T�^`� �' ��''''��` -`�-�A�--f /'lGH��'#2- SffA�.�Fi:2.� 1'1` fcv� ('„+.�JcL N l�,� S'r:''tv�Sa%,%L +{�';i;.s�.c.r2 (a�/- !G y2- CI�C��i - -j. Fi►�C(6S/-22�!Gy J� 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 detail d as possible. If necessary,attach a diagram. /�Sfo �5.�-�/�-�.�3'�• f'iLZ._�- �itc� l�'"��^--� ��c.��2 . 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. �' S 1- - � ^ �1L:- �-�s s fi � ' E-��='^`� " ��` "- =L'� �.L.vss + �..�� F�-� n.�.,,��.�. � ��-- �' �-r� i fir .� c_�c� lg.��C. Vehicle Claims please complete 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 • Injury Claims please complere this secfion .�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 ��:19G r�,��ar��r,� �Check here if you are attaching more pages to this claim form. Number of additional pages�• �_�� r j�Z T.��.��tC.x' 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 proeessed. Submitting a false claim can result in prosecution. Date form was completed_�/t� / �'' Print the Name of the Person who Completed this Form: i ►-�L G/�O�C ,�- ��.:f1S�-�� Signature of Person Making the Claim: ��'� � �� Revised February 201 1 3/19/2013 Dear Sirs, On Friday evening March 15`, 2013 at about 8:OOpm, I received a call at home saying that the Fire Department was at my building 1554-1556 Selby Ave and I better get down to the building quick as there was some kind of alarm and I needed to board up some windows. I dropped everything I was doing and ran to the building with the thoughts of flames,damage, ruin, and possible bodily injury. When I got to the building,the District Chief Ms. Stacy Hohertz met me in front of the building. There were no flames, no smoke,and no bodily injury. But there was my mangled front door with its glass lying on the floor. It was also cold because the firemen had shut off the heat. Ms. Hohertz apologized that the firemen had mangled and smashed my door with only steam being visible. She explained that a passerby had seen what the passerby had thought was smoke and called the Fire Department. Steam was escaping from the steam relief valve on the radiator just like it had escaped from the radiator for years previously.There was no danger, no smoke, and no smell. It was clear that overzealous firemen with a crowbar had bent and twisted my front door and broke the glass.There was no excuse to go that far. It was steam and it looked like steam. But they had made a mistake.They knew it was steam and they still turned off the boiler on a very cold night.We needed to relight the boiler, clean up the mess and board up the door. I am only looking to be reimbursed for the repair to the door and its glass replacement. I am enclosing that bill for$52426.The Fire Department claimed that they did not have our phone numbers. I beg to differ.We have been asked and supplied our cell numbers to the city many times in the past.We have owned the building since 1986.Why they could not find them is beyond me. How could they have busted up my building like that?The firefighters in St. Paul are great people and we applaud their efforts. But this was a simple mistake that pros should not make and we woutd hope we would be reimbursed for our loss. My insurance deductible is$500.00 so we could not report it to our insurance for payment. Thank you, '��l�''�� /�' d� l Theodore A. Kvasnik Kvasnik Properties I, LLC Owner � . � INVOICE � , � � PAGE: 1 BMPiR� DOOR S G6ASS C0. 3415 EAST 27TH STREET INVOICE NUMBER: 0128385-IN MINNEAPOLIS, MN 55406 INVOICE DATE: 03/05/13 612-729-4003 ORDER NUMBER: 013 62 4 7 � ORDER DATE: 03/04/13 � � � SALESPERSON: JASPER CUSTOMER N0: KVK01 KVK Enterprises 2190 Marshal Avenue Saint Paul MN 55104 JOB ADDRESS: 1554 Selby • � • Due upon receipt � - • � � • � • • y 31dg. 1554 Selby 'ront entry door ; �abor and materials to repair the front entry door ind frame due to forced entry with crow bar, etc. . dork order includes removal and disposal of all �ob-related refuse. NET INVOICE: 524 . 26 SALES TAX: . 00 --- -_---. INVOICE TOTAL: 524 . 26 . .... _..� .. . _ _ _.. __ _ , __ . ��3