Dieter ,-��:��iVED
AUG o 12013
NOTICE OF CLAIM FORM to the City of Saint Paul, Min���aCLERK
Minnesota State Statute 466.05 states that "...every person...who clarms damages from nny municipalin�...shall cause to be presen�ed�o the
Xoverning body nf rhe municipaliry within 180 days ufter the ulleged loss nr injury is discovered u notice stating rhe time,place,and
circumstances thereof,and�he nmoimt of compensation or ather relief demunded."
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 ,
�'t>„s� n �� �l%�l_', ; I
First Name P., Middle Initial Last Name �
Company or Business Name '
Are You an Insurance Company? Yes� If Yes,Claim Number?
Street Address 2c Z� P�n3�Hv tt-ST �'�'�
City �Ti �A�- State� /v Zip Code�� ��
Daytime Phone(�)2-�l-7��� Cell Phone�SI )�-�-3�-Evening Telephone(65� )�4L��-3zZ-
Date of Accident/Injury or Date Discovered ---�'�N"� Z7 ��� Time�%�� a 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.
5�� r.�.n P��z �a� P�s.�,v� �1 s�s F��-�-�f�i<-� P N� #��.�.r-z r,
A TP A< <� r� �,�-a �� K r�.��n �„r-r+�-,��- rz� �-���c f`Z c�.�✓f ���,n..�-�
�►t�- �:��[Nz� Q+- �{-� S�s�'€�i ��D i3�o�c�-- i�/nc+✓�Fc �-2
��NC-� y A i � f� E'�'RE:N�2=-Y1I71 T� 5�.'Si�FGT
Please check the box(es)that most closely represen[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
�ffi Other type of property damage-please specify ��C�- 6A� 1�f�5Tf�r7Y N�
❑ Othcr typc of injury-please specify
In order to process your claim you need to include coqies of all anplicable doeuments.
For the daims types listed below,please be sure to include the documents indicated or it will delay the handling of
your claim. Documents VJILL 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 daims: legible copics of any ticket issucd 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
I
Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims-ulease complete this section
Were there witnesses to the incident? Yes No �� nknow (circle)
Provide their names,addresses and telephone numbers:
Were the police or law enforcement called? No Unknown (circle)
If yes,what department or agency? . � .� � � Case#or report#L�- 13 �'-34'(
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.
��L� (��nrE+tuR.s'r /4J'�, .�i-N/�✓� /Lt N�" Z/(o
Please indicate the amour�j you are seeking in compensation or what you would like the City to do to resolve this claim
to your satisfaction. � B_SGf��%
�
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
Iniurv Claims-please complete 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 resul[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 was completed ��-Y �� �_L�
Print the Name of the Person who Completed this Form: �`'`� �� ' `- � ��c�(��
Signature of Person Making the Claim: ��� G'_` j-�
Revised February 201 1
JEREMY DOVERSPIKE
Polire Officer
POLICE DEPARTMENT �.
CTTY OF SAINT PAUL �"���'�?%,�
:� ,�
;.�;
367 Grore Srreet I�oic�e Mail:65/-2h6-9000 :2?!��
Saini Paul,MN i5101 Mui!Bas H:71697 ���
�N# 1'�� ��� -���
[f you have questions regarding your repon,call:
Saint Paul Police Records Unit (651)266-5700 �
�
Premier Fence, Inc.
1105 Homer Street Invoice Number: Dieter-Repair
St. Paul, MN 55116 Invoice Date: 7/23/2013
Voice: 651-698-4007
Fax: 651-698-1535
Bill To:
City of St. Paul
Re: 2026 Pinehurst Ave Fence Repair
Customer ID Customer PO Pa ment Terms Due Date
Dieter-Repair 50% Down & Balance Upon Receipt
Descri tion Amount
1-Western Red Cedar Gate Replaced
72" hi h Glenhill S le usin 1x6 Premium Kno Pickets with 1x4 Accent Board
Gate Com lete with Black Heav Du Ornamental Hardware
1-4x4x9 S4S Western Red Cedar Post& Hatteras Post Cap Replaced
"Includes Removal & Haul of Cedar Post&Concrete Footin &Gate
Subtotal 830.00
Sales Tax Incl
Service Char e Incl
Total Invoice Amount 830.00
Pa ment/Credit Applied 0.00
Pa ment Due 830.00
�
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White—sigNreturn to Keller
Yellow—Rep/Office copy ,
Pink—Customer copy
RESIDENTTAL
��.
1429 Marshall Avenue,St. Paul,MN 55104 Ph:(651)646-5404 Fax:(651)646-8575 MN License#20102806
GOODS & SERVICES RETAIL INSTALLMENT CONTRACT
Name � +F� Estimate Date -?r'�—/ Rep �w� L���,�
Job Site Address � Z " Hudson Page/Grid _ Cross Street
City �i�q,� Zip �a County 5� Ticket#
H Phone ��I-��'t�-��a� W Phone Permit Responsibility: ❑ Keller ❑Customer N/A
C Phone Fax Schetluling Reques# y/+�t�v�e•L��
Email
w000 BOARDS POSTS SPECIAL WORK TO BE SPECIFICATIONS
VINYL DONE BY CUSTOMER
IRON/ALUMINUM A• ❑ SIZE A. ❑ SIZE A. ❑ INSTALLATION SPEC
VINYL CHAIN LINK g, � MATERIAL B. ❑ MATERIAL p, � ��WES CLEARED OF
CHAIN LINK OBSTRUCTIONS B. ❑ FENCE TO BE "+/-
WALK GATE LENGTH C. ❑ GRADE C. ❑ STYLE OFF GROUND
D. ❑ SME ❑ HATTERAS g, � LINES STAKED BY C. ❑ PRIVATE LINES
DRIYE 6ATE STYLE ❑ COPPER CUSTOMER WHERE
❑ FLAT WHAT
E. 'SPACING ❑ OTHER C. ❑ CUSTOMER TO BE ON
COLOR HEIGHT SITE TO LAYOUT WfTH
F. ❑ OTHER INSTALL CREW
sK�rc SPECIAL INSTRUCTIONS
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We propose to furnish and install in accordance with the Acceptance of proposal:The price and specifications are satisfactory
above specifications for the sum of($ ��/'�� ) and acceptable. I/we hereby authorize you to proceed with the work
with payent to be made as follows: _i- as specified. I/we agree to the paymer�sche ule as ou ' ed.
Deposit �� �,��.��')� Accepted by Date
Authorized Representative �
���Qn�.p o (�a;n,�?�{ /� This proposal valid for ��day
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