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Kaluzniak rcc�.t I VED APR 18 2013 NOTICE OF CLAIM FORM to the City of Saint I'�'s�,1�4'ih��$p(ta Minnesota State Statute 466.05 states that "...every person....who claims damages from any municipality...sha[I 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 Paul Middle Initial N_Last Name Kaluzniak Company or Business Name n/a Are You an Insurance Company? Yes/No If Yes,Claim Number? Street Address 7317 N. Shore Trail N. City_Forest Lake State MN Zip Code_55025 Daytime Phone(651)253 - 1444_Cell Phone(651)253-1444 Evening Telephone(651)253-1444 Date of Accident/Injury or Date Discovered Apri15,2013 Time 4:00 pm 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. The City Water Department failed to turn on my residential water at 180 Wildwood Ave,Birchwood,MN 55110 which is my rental property.The city came out on several times and insisted the water is turned on and the issue was between the meter and curb stop,when in fact they had just failed to turn on the water. I had to hire a plumber to prove that the issue was not between the meter and curb stop a a cost of$600(see attached).The plumber talked with the water emergency people(651)266-6874 numerous time on Saturday explaining why the issue was not between the meter and curb stop. The emergency people would not anything and said to call back Monday 4/8/13. I called the emergency number Monday morning 4/8/13 and they came out and turned on the correct valve and the water was restored. The issue was due to the city not turning on the valve to my house. I am also out two days rent$108, therefore I am requesting payment of the plumber and loss of rent for a total af$708. 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_Failure to turn on water ❑ Other type of injury—please specify In order to process your claim v^•� „PPd to include copies of all aqplicable 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 $SOO.OQ; 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 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 Unknown (circle) Provide their names, addresses and telephone numbers:_Tom Thill Hugo Plumbing 651-433-4866,Peggy Olson, renter 651-228 3825 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. na 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._Cost of plumber$600, loss of 2 days rent $108 Vehicle Claims— lease com lete this section x check box if this section does not a 1 Your Vehicle: Year Make Model License Plate Number State Colar 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 �lease complete this section x 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 x Check here if you are attaching more pages to this claim form. Number of addiNonal 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 was completed f J�� Print the Name of the Person who Completed this Form: Pft vl L ��1 L+U 2��/d � Signature of Person Making the Claim: Hugo Plumbing & Pump Service, Inc. Invoice 9600-180th Street North Forest Lake NIN 55025 �ate Invoice# � 651-433-4866 4/6/2013 04211 Bill To Paul Kaluzniak 7317 North Shore Trail Forest Lake, MN 55025 Terms Customer Phone Due on receipt 253-1444 Description Qty Rate Amount Saturday Service call: 600.00 600.00 Job address: 180 Wildwood Ave. in Birchwood No water call -city removed meter and told owner that problem was between meter and curb stop,and thought line was frozen. Ran hot water thawing machine down line 60'or so and still had no water. Contacted water department and was told curb stop valves were not touched by their department. Connected hose to neighbors house to get water for the weekend. (Tom&John) I Thank you for your business! Total $600.00 A finance charge of 1.5%per month(18%per year)will be charged on past due accounts over 30 days. kaluzniakl - Yahoo! Mail Page 1 of 1 --- - -- � _ Search Mad Search Web Hi,Paul ��,.��INBOX CONTACTS .. CALENDAR Claim fortn Compose Delete Move Spam Actions � InbOx CI81m fO�m from Quicksell,Liz(CI-StPaul)to you Apr 8 '� Conversations _ Drafts 2 At.a ��.a .,.,.-.�.., , ��'�how ; Save all to ,u�c 36K6��.. � ( Sent ', I 3 �'��. i �',Claim I Spam(2) form � '. ...2011.doc Trash ---_�--- --- , Sav� Saver .. .FOLDERS ..... ..... . 2010 Job Search Hello Paul. Attached is the form that should be filled out to file a damage claim.Please fill out as wmpletely as �; possible and attach any documentation you have.Please mail it to the address on the form.Thank you. Alternative Realty ' American Family Insura. Liz Quickseli caroi Water Ufilify Tech Ill DACHSCHUND � 1900 Rice Street Saint Paul,MN 55113 desi nwisemedical Ph: 651-266-6875 9 � Fax:651-266-6878 � � liz.quicksell(dici.stpaui.mn.US �� evite bounced emails Funny Job Search Misc Job Search MN Job Search MN 2009 �� Kaplan Misc ' �� Notes Paul Synced Messages Temporary WFMRG Wildwood x --�MESSENGER I : --APPLICATIONS -� , �------� ��... � i ,.��d � � � - �.�, � �_�'"�.� i�ry��.�:.. :�°`�.. i �-------J ' „�; http://us-mg6.mail.yahoo.com/neo/launch?.rand=02jfjaae912jv 4/15/2013