Loading...
Schwartz NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota Minnesota State Statute 466.05 states that"...every person...who claims damages from mry municipality...shall cause to be presented to the governin8 body of the municipality witfun 180 days after the alleged loss or injury rs discovered a notice stating the time,place,and circwnstances thereof,and the mreonnt of compensation or other relief denwnded" Please complete this form in its entirety by clearly typing or priating yonr answer to each question. If more space is needed,attach additional sheets. Please note that yoa wBl not be contscted by te�ephone to clarify affiWers,so pmvide as much information�necessary to exp)ain your claim,and the amonnt of compensation being reqnested. Yon will receive a written aclmowledgement once yoor form is receaved. The prncess can take np to ten weeks or bnger depending on the natare of ponr cJaon. This form mnst be s�d,and both pages completed. If so�thing does not apply,write�N/A'. SEND COMPLETED FORM AND OTHER DQCUMENTS TO: CITY CLERK, 15 WEST KELLOGG BLVD,310 CITY HALL, SAINT PAUL,MN 55102 First Name �A�'� Middle Initial�Last Name ��+�trS.p.'�t Z Company or Business Name Are You an Insurance Company? Yes� ff Yes,Claim Number? Street Address ���� �}�FXiP�1 f�1�-. City � �AVc_ State �N. ZipCode 'rJr'J��� Daytime Phone(�051 )�-25�i5 Cell Phone(_>; - Evening Telephone �[(,.,_����- 254'5 Date of Accidend Injury or Date Discovered�p�R- �• '2013 Time �:15 �,� 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 damages. 1��c�c� Hut�tE� t�P c�►•y �s=� �Ru�c'S 1 n► P�l,��� - DAan1u�� �v �P�.i� �No ��s���r�s��. -- -�owir�� c��s �o ��C�cIZ �e�n �aE R�t►-- ����y 'N�"C YY1iA11�'CA11�ED �rv�-sr�� �� N����a� 'Fc�� ��,v��,At, L' � �s�� .�-�–�' '��1a— � � –o Please check the box(es)that most closely represent the reason for completing this form: ❑My vehicle was damaged in an accident (��Y� ❑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 pmperty ❑Other type of property damage—please specify ❑Other type of injury—please specify , In order to process your claim�on nced to include coDies of all a�ulicable dceuments. I . , 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 bilis 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 daznage claims:two repair estimates if the damage exceeds$500.00;or the actual bills and/or receipts for the repairs;detailed list of damaged items O Injury claims:medical bills,receipts O Photographs are always welcome to document and support your claim but will not be returned. Page 1 of 2—Please c�plete and return both pages of Claim Form Fa�ure to complete and retarn both pages wiil resnit in delay in the handling of yoar claim. All Cla�s-nlease comnlete this section Were there witnesses to the incident? � No <Cinknow (circle) Provide eir�s,addresses and telephone numbers: �• �� rAVzK�� �rv�'o(LC w►c n,-I- �r �j�vE�- �.00AL RESi CE N'1 S Were the police or law enforcement called? e No Unknown (circle) 5� ff yes,what department or agency? �t.� .A, Case#or report# ��G Jq`1�9 C ���� Where did the accident or injury take place? Provide street address,cross street,intersection,name of park or facility, closest landmark,etc. Please be as detailed as possible. If necessary,attach a di �d,[�E�t ��C�t� ``�'�t'�I�ti�CA� � Gi21C�GtS — �AS► �p 6� }'�U�E� Please indicate the amount you are seeking in compensation or what you would like the City to do to resolve ttris claim to your satisfaction.�81fY��i'QStM�hk �Oe. 1�t;1, R6PA`►'Q.S e TOW1►�lG GdS't'S (�,VS Yln�Sc. C.c�STS -- (�� t..ts�> � 1 B��i �"1 Vehicle Claims- lease this section �check box if this section does not a 1 Your Vehicle: Year l� a Make Model CV4�P ^ iF15O License Plate Number 14 ;}1�iJ State �A►a Color Qk.$Wc. Registered Owner l�ut- Sca�wAa.'rZ Driver of Vehicle c.. A(t�-tZ Area Damaged �Rn►�T �IJD �JS'(��.�5\O F:J SE-E '�5���1P'iL-�'S � GC-�`�`nS� City Veiucle: Year Make Model �ND �Tp�. License Plate Number State Color Driver of Vehicle(City Employee's Name) Area Damaged Iniurv G7aims-nlease comnlete this section (�kheck box if this secrion dces not auvlv How were you m�ured? 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 inj�ry? 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 th�claim form. N�►ber of additional pages � ,+ �U?O S , By signing this form,you are stating that all infornwtion you have provided is true a�d'correct to the best of your knowledge. Unsigned fonres will not be processed Submitting a false claim can result in prosecution. Date form was completed �- �0-20�� Print the Name of the Person who Comple this Form: �Av�, J. �'t�W��WT2- Signature of Person Maidng the Claim: Revised February 2011 On Wednesday Mar 27 2013, I was returning home from work and noted that all on street parking spots were taken. I then drove around the corner and saw that there were some spaces in the back parking area of 1220 Sherburne where I reside. I proceeded to Syndicate Ave by way of University and entered the alley off of Syndicate heading east so that I could back my truck into one of the available spaces. My truck became"Hung- up"in some very deep ruts in the ally that aze created by vehicles using it after the winter snow falls. Sun does not get that azea to do any melting because of a vacant car dealership building thus resulting in some very serious ice buildup. I was stuck to the point where I could no longer move my truck in either direction. At 7:23 I placed a cali to the St. Paul Street Maint. Dept requesting to speak to somebody about the situation that I was in, only to be informed by the person on duty that the city does not maintain alleys. A long discussion pursued and I again requested to have somebody in a supervisory position return my ca11 ASAP. I then ended the ca11. The next call at 7:29 was placed to the St Paul Police department about my truck blocking the alley way. Parking enforcement was dispatched. At 7:37 I received a return ca11 form Mr. Ken Nelson (Street Maint. Manager—651-353-3793)explaining the situation to him he stated that same about the a11ey ways and also refused to come out and access the condition of the alley,his only comment was that he could call the police department to which I informed that I already placed that ca11. Two officers pazking enforcement officers arrived viewed the situation and could not believe the conditions stating tha.t it was a very dangerous condition. They upon my request placed a call to have a police officer come out and assess the conditions as I wanted my vehicle out of the alley.A police officer(Pil Jeon) arrived and also agreed that the conditions were very dangerous and unsafe for anybody that uses the alley in that azea. I requested that he make out a complaint which he did(CN # 13059749)and informed me that they coutd request a tow truck to get it out,but I would have to pay costs for a"drop fee"chazge. I agreed to that and stated that I would be submitting the claim to the city for the cost expense incurred. COSTS REIMBUSMENTS: Towing company drop fee(Rapid Recovery Inc) $80.00 (attached copy) Photo processing(Walgreens) $4.46(attached photo prints) Police report(St Paul PD.) $0.75 (attached copy) Front Suspension Caurtesy Check(Firestone Service Center) $89.89 Documentation Copy services(Fed-Ex-Kinko's)and postage $5.00 COSTS (Needed)REIMBURSMENTS (Estimates) Ball Joint replacement(Upper-Lower Left)$453.19 Ba11 Joint replacement(LJpper-Lower Right) $453.19 Front Wheel Alignment Service$84.99 GRAND TOTAL REPAIR COSTS: $1099.47 ..:}'" �: ri: '�,t*..1; a A .�;�-. �S(�*, . f` �'h F�a �' '..Y � ��� 7^^sr k� � s M �. Fr ��.�= '+'�# � t '' ��s.'.�, J ��� *�`��'���a ��?��� "��� `,���"'�'���� �` �� �tV� '.. � �#� •���9��;� :+� k�t�d� -� ��� �s •.����•IACkcnrts �: �` � � �� '� �, i 7 �� ��. .:� ".�. �.� ��'P�D �1!;� � - � g � �r '��k ��,. _ �#f+`� �Spatch ttrne �u���e �'�'v `��af�avv: ��er` ���� Na�►ae ��. j�, �, � . � , , A�ress �� � � �� � � �" � ��� � �� � �� � � . � ,k ._ � ��s, - `��� r +�'� ��, �� �.�'�;�� �' � lf� �� y"` � �e 1 �'b� -�,� ��e ,,�k L �rraeter � _ � . � � _ . .:_ �v _. .... _. �._ ..�, � .r , r< ; .,, V`� - '1 � �� �c�w ❑ ,�u�a S�` � �r�� :� 'F� �`,�� �,� �-�-�-- f� €1tt�er _ �s Q '�( ;� !� �' . � �-�=----� < ��: � � �e��ait: � � � lU�ea,ge: rt►ites@: �� � Storage: days�: [V�.Ct�c,�s: : , �� P.#1.� �taf: � ` Cash O C� C7�t�`�sa Ct Ma�rcard' l4��n# .T�c: Narr�t�:�` "ft�tal: ���� Comrnents: E�Dafe: �e�ero�By: �Cc�l�: � Pu�t,� f0E As an"eq�t aPPerNnhY emRb9e�'�es canpary�s paGr.y,as weq a4�aad�e lax�'P�ol� 6�9h�niwA Aasdd ert race.color,�¢on.sac,Naqunal o�.PYysWal i�eaF,ar ape wflh�ecf�i�i�6duais wln arB 2[�18 y�s ot age. : WORK ORDER # FIRESTONE COMPLETE AUTO CARE SERVICE ADVISOR 087708 491 JACKSON ST 04 JEREMY 04/06r 13 03 58�M SAINT PAUL, MN. 55101-2319 651.224.5868 SCHWA�TZ PAUL 1990 FORD PICKUP F150 1220 SHERBURNE A'v`E 6-300 4.9L SAINT P�UL �,^N 55104-252$ LIC# NKC453 MN VIN # 1FTE=15Y9LPB42867 612.299.7504 IN 04/06/13 12:47PM EST. MILEAGE 108,000 Store# r,r�o2; Recommended Services not Authorized by Customer Unit Price Extended Price Status Description Qty Parts Labor Job Total Cat. Total Total Recmd ALIGNMENT SERVICE g,;,g9 Sy�npt�m - 0 0.00 0.00 ALIGNMENT SERVICE 1 0.00 84.99 . Originally Requested Service > 84.99 84.99 Recmd BALl JOINTS (Upper-Front,Left) 45_>.19 K80Q26 UPPER BALL JOINT RL 1 113.99 0.00 REMO`JE & REPLACE F BALL JOINT- LEFT, 1 0.00 339.20 �PP�R & �O'�/1�'ER System Failure - Required > 453.19 538.18 Recommended Parts: 113.99 Labor: 424.19 Subtotal: 538.18 Shop Supplies: 25.00 Tax (7.625%): 8.69 Total: 571.87 THESE PRfCES ARE VACID FOR 3fl DAYS Labor ch�rres are baseci on 'Menu Items'of a predetermined amount or the flat rate charged per the MitcheN Labor Manual @ $106.00/hr. ALL PARTS AR,E NEVV UNL�SS NOTED OTHERWISE �4�w,I��a�e$t�a��Ce�r��leteAutoCa��.com ��F n�_A���C��I I 10392 �s �1 �, . ;s, . Rerc ,�_�,�3r�, c�d.-,c, ��ss� ravPrc� :irla fnr i/1r'arrantv Infnrmatinn ,��� ,. ��same day piCkup Create assorted gifts and pick thf � •'���,�'�/� •Coliage Prints •Photo Books •Calendars •Pos? �+ �� �select produc[s and locacions �0�,''�O� �V I� .��UI\i�� ROAp C V� ROSEVxL(.I: htl� 55113 651••i�6-f3369 415 13435 0O'1 t)4/01/201;:3 2:21 pM 4 ��Q PHOTOFINISIiING 547;���� 0 0� � p �� 16 MOD ��� � SUBTOT,aI �0� � � SALES TAX q_; . ,, �1, 16 �o � ..• '' I� 5X �.),30 �� N COTAL °D Q ASH �m,�, CHANGI� �C/ a,,d�W, .,OrJa p°�0.. Schwartt P� �r3�J`f �'�a¢`°•n"3t°: (651)644-2�45 THANK YOU I=OR SHOPf�:: �, et Q,;a,:, ���°.;mgoa�T NG ���f WALGF,EI::rJS :��N T,��,' YOU COULD I�AVE SpVF:) B'� USING 1'OUF; ��;;;�;a�9 1HR - 14 Kiosk Prints DIG BpLqNCE RI�I�QRDS CAi�:) Tp�)��yi �, ,y,,,ot APPLY, SEI:: PROGRqM iULL-;; FORRUET,�I:LSIONS ?�:d Q�p 04/01/13 02:12 PM Store #2002 mi3i��9; Order #990402974 DID YOU KPd�)W THq�- y�,�� i,��p� EARPd PIaT.NTS �,9��� a��„ TammY ON HUNDRED,, OF ITEIH:� IiV�•STORE �y►�(� r4 0��, a��� ONLINE� � , , pD�°� NICKUP TIME: 04i01%13 02:39 PM INFORMATI)Id. RESTR];;TIO Jl�i qpp ��Ofi<< �'�� �3��n�`'<' PROGRAM RIJI ES FOK C)I�TpI►.,;, pLF'��SC:�rGO ��¢� TO 4�ALGRENIVS.COMIB,��l;qy��„ �''' 1 o IIII RFPd�� 0200-•2;�18-43!i0-13U�1-�)'03 b� 4 0 1 IIIIIIIII�III��II�IIII��I�II��� IIIII�IIII�'IIIIIIIIIIII�I �� �[T('� _ __ IIIIIIIIIIIIIiIII ��� 1\1 V� �� ��•.ha1�lnCe` � � ��� k � � I Custar�er Invoice � � FIRESTONE COMPLETE AUTO CARE Service Advisor: 087708 JACKSON 04 JEREMY 04/06!2013 491 JACKSON ST 651 224 5868 SAINT PAUL, MN. 55101-2319 1990 FORD PICKUP F150 SCHWARTZ. PAU� 6-300 4.9L 1220 SHERBURNE AVE Lic#: NKC453 MN Vin #: 1 FTEF'5Y9LPB42867 SAINT PAUL ti1N 551 U4-2528 In: 04/06/13 12:47PM Mileage 109,908 612.299.750�' Out: 04/06/13 3:58PM Store#010022 RETAIL SALE Rev Hist Un�t Extended Job Description /Article# ID Qty Price Price Total COURTESY CHECK 04 CUSTOMER CAME IN FOR ALIGNMENT. FOUND BOTH FRONT WHEEL BEARINGS LOOSE TIGHTENED 'J',JHEEL BEARINGS. RETESTED SUSPENSION AND FOUND THE UPPER AND LOV��ER BA.LL JOINTS ON BOTH SIDES HAVE MAJOR AMOUNTS OF PLAY. CAN NOT PERFORf�-1 ALIGNMENT UNTIL BALL JOINTS REPLACED. COJR-ESY CHECK 7046930 45NS 1 N/:; N!C WHEEL BEARING (Front-Both} 1 04 84.80 000 TIGHTEN BOTH FRONT BEARINGS 7003303 45NS 1 84.�) 84 8G Technician(s): 4� Jt�P�IES PANUSHKA Payment H�story Summary: �CA Check 9543��. 89.89 "2098 Parts 0.00 Total Tenderec gg.gg Labor 84.80 Shop Supplies 5.09 S ub-Total 89.89 fiax (7.625%) 0.00 T�tal �.'88>> I have recei�:e� tl�e abqve goods and1or services. If this is a credit card purcha:�e � agree to pay and comply with my cardholder agreement U•�ith ?he �ssuer Rev Revision History: Amt Init `;�,stor�e� Signature 1) 04/06/2013 03:22PM 89.89 SCHWARTZ; PAUL II�! PERSON 2) 04/06/2013 03:46PM -90.09 SCHWARTZ, PAUL 1�J PERSON Al/parts are new unless otherwise specified. Declir:ed V`d�rk: I acknowledge notice and orai approval of ALIGNMENT SERVICE an increase in the origin��l estimated price. BAL.L JO�N�S ;�Jp��r-�ro��t !eft:� Signature or Ir �tials ��;vv.�ire��tt��e�o�piet�AutoCare.com ..nF .�.,a�SE JGS33F c5�.1C39� REr'-L;� �.. P�I�� I ��C' �.� fiac� rAVCrcA ,s,-ir� f��r;Narr�ntv infnrmat`snn '"' Saint Paui Police Department Pa9e 1 of 3 ORIGINAL OFFENSE / INCIDENT REPORT Complaint Number Reference CN Date and Time of Report �$�� 03/27/2013 22:27:00 Primary offense: INVESTIGATE-AND ALL OTHER Primary Reporting O�cer: J20f1, PII Name of/ocation/business: Primarysquad: 167 locationofincident: 1220 SHERBURNE AV Secondary reporting officer.� ST PAUL, MN 55104 Approver.• KIII, Tina oistrict:Western Date&time of occurrence: 03/27/2013 20:22:00 to Site: 03/27/2013 20:22:00 Arrest made: Secondary offense: Police Officer Assaulted or Injured.� Police O�cer Assisted Suicide: Crime Scene Processed.� OFFENSE DETAILS INVESTIGATE-AND ALL OTHER Attempt Only: Appears to be Gang Related: Crime Scene Method 8 Point of Entry TyPe: Public domain Force used.� oescript�on: Highway/street/road/alley Pointofentry: Method: NAMES ST . PAUL POLICE Complainant Schwartz, Paul Julius 651-266-5700 1220 SHERBURNE AV W Apt 9 DATE 04/O1/2013 MON TIME 14:52 ST PAUL, MN 55104 NONADD # 344700 Nicknames or Aliases NONADD # 13059749 POLICE $0,75 n►ick�vame: TOTAL $0.75 ':-Gt�Skt �,75 Alias: CLERK 1 072845 00000 AKA First Name: AKA Last Name: Details sex: Male Race: White DOe� 7/13/1949 Resident Status: Hispanic: Age: 63 from to Phones Home: 651-644-2545 Cell: 651-494-8676 Contact.� Wp�,- Fax: Pager. � SP5427C5C27804E � Page 2 of 3 Saint Paul Police Department ORIGINAL OFFENSE / INCIDENT REPORT Comp/aint Num6er Reference CN Date and Time of Report 13059749 03/27/2013 22:27:00 Primary offense: INVESTIGATE-AND ALL OTHER Emp/oyment Occupation: Emp/oyer. Identification SSN.• License or/D#: License State: Suspect UNKNOWN Nicknames or Aliases Nick Name: Alias: AKA First Name: AKA Last Name: Details Sex: Race: DOB.• Resident Status: Hispanic: Age: from to Phones Home: CeIF. Contact: Work: Fax: Pager.� Employment Occupation: Employer. Identification SSN: License or ID#: License State: Physlcal Description US: Metric: Height: to Build: Hair Length: Hair Co/or. Weight: to Skin: Facia!Hair. Hair Type: Teeth: Eye Color: Blood Type: Offender lnformation Arrested: Pursurt engaged: Violated Restraining Order. DUI: Resistance encountered: Condrtion: Taken to health care facility: Medical re/ease obtained: I SP5427CSC27804E Saint Paul Police Department Pa9e 3 of 3 ORIGINAL OFFENSE / INCIDENT REPORT Complaint Number Reference CN Date and Time of Report 13059749 03/27/2013 22:27:00 Primary offense: INVESTIGATE-AND ALL OTHER SOLVABILITY FACTORS Suspect can be Identified.� NO By: Photos Taken: Sto/en Property Traceab/e: Evidence Tumed!n: Property Tumed/n: Related Incident: Lab Bio/ogica/Analysis: Fingeiprints Taken: Narcotic Analysis: Items Fingerprinted: Lab Comments: Participants: Person Type: Name: Address: Phone: Complainant Schwartz, Paul Julius 1220 SHERBURNE AV W Apt 9 651-644-2545 ST PAUL, MN 55104 Suspect NARRATIVE � ICC not available in Squad #1193 On 03/27/2013, at 2022 hours, I (Ofc Jeon/167) was dispatched to alley behind 1220 Sherburne Ave for a dangerous condition. Upon my arrival, I observed a Ford truck MN #414HDN appeared to be stuck in the alley behind 1230 Sherburne Ave. The owner of the vehicle was SCHWARTZ, PAUL JULIUS (DOB 07/13/1949, 1220 Sherburne Ave#9, � H/P 651-644-2545, C/P 651-494-8676). SCHWARTZ stated he drove his truck east bound on alley and got � stuck behind 1230 Sherburne Ave. I It should be noted that the alley was icy and had 7 to 8 inch dips and approximately four inch wide ice ruts. This report was generated due to SCHWARTZ's request. PUBLIC NARRATIVE Informational report SP5427CSC27804E -� �� �\ � r � � �„' � � a � �• � � � � ' . : c�^}'� I- .,,.. :� :�... , v►` ,lA,� � •' ... y�• '�� ai - �+� "-'�:c - e "�: ..,,,�. ;y ►,::�'":.,�,�f . � �iR :;�l;s �t 'tio Y.F•"e� � I�•' .^4 a'. . ...- :,� ; } ,.„. .. � :�,: �'�" ` .,�.-_ °` j 4 ;,t .a+l1k'" . s# '!•�:',, �: ��f� .� , . , � (�� 1 , 1 �.,.J �•► ' � �.. . � �i• �,_ , , . � � . �` l ` l '` �,,•^� G��9,,,� � �►�'�'� • • �Y . ,;�`. � '�,.. .� > . :�;, . ., �. .; ! . � � ., � i s - _ • 'a • , �'���.. '�• ',' •~~ • •� • �� ' • , ' �• • � , �, , . .1 . ' , . - . - . . . �, . •�' s .,�.� � ' �'�..�, iK .�,,. ,,.� , ,�,� - . s.�, i � � , �., . -� � . :�. .� _ � � �'►�� _ �►. � ' • , .,,, � ��:� �,� " ; s . �. "� . ��, ' •��I{. ' � ''�'�. , ,� w � » � .:,,� . .. � �: !A''�1,,� M ' . �;, , w»"' , ' , �,(,� � . _ . 'a � .;�:_ . ' •� �,!�' . . _ ,�t . . � R,. � � ,�'�-s.., , - . � � '�:: , . .�� .� %� � ��.;� ".�;. ' r'J, .:�. �k T � � " �� � � ���1 , F .._ �'.r .`� i . 7!�'��., . . Y �.� w�' -�� � �` '_.►� � � � , " � � _ . .� ��� y�'� ��± �� '* » � ,� ,. , '� .�► " `w' . . �'s_i . � ,.;.f �;� ?G. t� i. <�: _ I� ` � . I ` #`, ` • .; I• c y�;, 'ti.: .,� y�•= � :<' "�.x ' l,�, �,�- v. � 44 • �- — - .. � � �� ,� I . . - -- ..�°� _ J � ' . .�_ �� . -:��� - . i�''�r� _�,c �� .. 3�`. � � ��w�, * ' J�" �:"� . �. � �y � ���.. � r.. � � �� � _. �._.��. � • .:.,� t � ''�, �� , ��Y:;�- l"vM' � �\ I , ,�• -�•w�"�'�!R��� �� ..e.�_"'° � �a.�ai . - ' � '�F :t.___ ..�- �'� � sY+W'^ � . �+ •