Hannig i
RECEIVED
;
AUG 12 2013 ;
NOTICE t)F CLAIlUI F�RNI to the City of Saint Paul, llrlinn ota
�GITY CLERK �
iafi�anesvi�r Srutr Snarstz�1b�.�swtes titat "...PAE�'L'�7EPS01S...q'IlV CIQf)AS LI(tJ9q�QCS�PU(A AL')!ltYtltCl�IfJIJi}.._SJ1tIlr C!/M.S01Q bl PY2SCl7t'lI IO tIf@ i
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rircumstirr.ces rfierre�:ard rhr amouni o/'corapenurrinn or olher rrlief rle�sarcfsd."
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Pkase comptete tt�s forru in iis entirety by cieazly tt'p�ng+or pt�nting yaur aus�er to each t�es#ion. If��ore sju►re is
needcd,attach aciclletonat sheets. Ples�se note t�at}au��i�t be contaeted by tetephone ta clarifj sutscrers,so pro�ide as
nwch inforrnatfon as c�eeessary to explatn}vur�clain►.s�d t}�e arnnurK of ccxnpensatk�n bdn�reqaested. 1'ou aiU receii•e a ;
tiYritten�Ecno�ier�bernent once yaur fonn!s recetved. The proeess c�ta1;e c�ta t�weeks or Ianger de�ending cx�the j
r�tnre nf yoar clnfm. ?his facm must be si�eii,and both pages crnuptet«3. ff�omething cbes not aPP�S��'rlte°N/A'. _
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SEND COh�PLETED F4RM AND UTHER DOC[�iVIENTS TO: CITY CLERK, �
15�'EST�ELL�+GG BLVI), 31i� +CITY HALL,SAINT PAUL, hIN 55102 �
First Name �-�e�1� I1Fiic�dte Initial �La�t Na�t�e ��'�r�:
Company ar Bua�ne�Narr� ` 1 �� t� s i
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Are Ycx�an Fnsurdnce Cun�pany'? Yes N Ifi Yes_CJxin�Nunfier?
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Street Addr�s �—1 � . ��� -
CiC}� �_ f-�z.�\ Stat� t—'I r.l Zip Code �5 I�n
Daytime Phone(�}�5��.Cell Phone{1cS 1'}�I$�l�f�/�O.Evening Tel��hone�g c6/�'3 1 O�o� i
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Date of Accidznd In}ury or Date Disc:overed f� Time an�i pm ;
PEe��sz stace,in detail,what occurred {happened),and cvhy you are submittin�actain�.Plea�indicate why or haw;�cau _
fe th City ot Saint P�uf or its ei�ploye�s• e invo v d and/or nsib for 4�o r darn��es. � �
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Plea�check the box{es)that�nb�t clo�Ey represent the reason fvr comj�letiE�g this form: '
�My.�ehicie�vtu c[arr�ed in an accident ❑M} vahicte�vas dartuiged durin�a tow �
�t�+Iy vehicle�^as dan��d by a poth�le orcondition of the street D My vehiele wa�dama�ed 6y a plow
❑ y vehicl�was w�rongfully towed andlor ticketed �I was' jur�d on C'tY property ;_
Chher typc Uf property darnage—plea:;e���� a 0 v1 Q� �
+Chher type of injury—plea.�specify_ � Y1 C. ql� 1 ;
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In order ta process your claim�°oo need to imdnde copies of a!t ap�Iicable tlacuments. r_
Foc the claims types tisted beloar,plea�e b��ure ro inciude the dc�eurr�eits iadi��ed or it will delay the handlin�of �
yourclaim. Docurr�nta WrL.L NOT be rectarned and becorne tt�e property of the City. S'ou ar�encaurage�to ke��a i
copy fac pjxics�lfbeFote submitting yourclain�form.
O Property damage ctaim�to a vehi�le:two zstirn�tes for fhe rep�tirs io your vehicte if fhe darrrage exczeds �
�SOU.00; or the�cxua!bilis and/or receipts for the.repairs �
O 3'owin�claints:le�ibt�sopie�of any ticket ia.eu�d and a capy of the intpvund toi receipt ! I
�O�ther propertv damage c.laims:twa re���ir estinratzs if the dama�exceeds��i1U.00_or the actua!bill�
-andfor receipts for the repairs:detai(ed list af darrt�ged itenb
O tnjury claims: n�edicai bitis,receipis
O Photagraphs a��tlw�apa wefconre to documene and wpporc your ctaim but�a•ilt not be�turned. -
PagQ i of 2—Please comptete an�t return both pages oP t7aim Form ;
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FaBure ta complete and return bot�f�pa�es r��ll result in delay in the handltt�oi y�ir ctsixn,
�1!Claims- ►Liease compleie this section
1�fe�ther�witnes�s to the ittcident'? Yes� Ng� Uakn�wn (circle) t� (��
Pr�vi � eir name�,a re.,�s and et pha«e nurr��rs: kJ� V'i�h - 7� - � I � t,� -�IGI��
c� ���r��o�.�P....�-� C �a�� A �! '
�h��re ihe pc>#ice or Ia�W enfarce�nent c�lled? �es No Unknowe� {citcle) i
If ves,�YhaF rl�p�i�tment or��ncy? �Fne�or repoi�t# �
f
1L�fie��id tt�aa:idec�t c�r injnry tat:z piace' Pro4ide str�t addreas,cro:s stre�i,interrectio . ame tvf pa �cif't. ;_
efosest t�ndmatk,etc. Please a�c�e iie s �ibte. If n ssary, ft��h�dia ram. d^� ����-��b� �
g � 1����►h � e ;
Please indieatz the a�naunt y are ac�t�it�in�oxn ei�s�f io or wh t you��ocild ti re a C�ty to a tu resolve tbi<clairn
t yt�ur s�€isfac:tion_ � ✓C�i C. S
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1�'ehi�e t7a - Iease cont ete thfs seet�oA C3 cheak box if this section does not a iv
Yo��r Vehis{e: Y�r 11�1ake 14Inr1eS
L.ic:ense Plate Nun�ber SYaEe Color �
Reaist�red O�y ner _
Dri�•er aF1�el�icle
Area 1?�anr��ed
Cicv�'ehicle: Y�ar i�lake Modaf
Licen�P.t�etz Number State Cc�ior
Drivecc�t'�ehicle(City Empioyee'sName) -
Area�D�arrraged �
IMurs Clalms-ulease compJete this sectfon �check box if this�ectian da�not applv - .
H4LV lk'Cf�}OU IC1JUtC{���
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tiVhat part{sj oFyoi�r h��iy w�re injured?
Have yvu sauabt tr�dic:�f tr�atmens'? Yes Na Pt��ning ro Sc�k Tcea�tme�t{ci�cl�}
ti�hen did you receive c�atrnent'? (provide date(�)) -
Nar�t�uf I�Ieilicxl Prov'scler(sj:
�d���, Telep#�ane_ �...,
Uid you miss�rUrk�.a re�;ft of vour injury' Yes Na _
bVhen ditl you mi�s work'? � {Pro�1ide d�te(s})
Name of yc�urEmplayer: �
Addre.� Tetephon$ :
4 .,_
�heck here if f ou�re attachl�i�more pages to thLs el�im f�rm. Number of addlttona! pag+¢��.. --
�
$y sign.ireg this fnrm,you ar�s1a#ing t1�at all infonnatiu�s you J�av�prr3vitlec�is tr�e and corrert ta t�:e Best
fl#'yaur kraQwt�dge. L>Trrsi�r��d fornrs svill nvthe�roc�sserl. _
Suhtnitting tz fnlse tlaim�r�n resr�lt itt prvsecutinn. Date form�cas comgleted � � l�
Print the Natu�af the Persan�rho Com this For.w: S � � Q11 V��
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S}�ture tifPers�n l�iak3ng the Claim: �
Restised Fe�xu�rtl'�1 1 -
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��oF��s Restoration Professionals
505 Minnehaha Ave.W.
Saint Paul,MN 55103
Phone:(651)379-1990
Fax:(651)379-1991
License#BC396147
SPRINGER#
SPRINGER#
DESCRIPTION QNTY REMOVE REPLACE TOTAL
1. Emergency service call-during business 1.00 EA 0.00 126.91 126.91
hours
2. Water extraction from hard surface floor 200.00 SF 0.00 0.22 44.00
3. Clean floor 200.00 SF 0.00 0.30 60.00
4. Apply anti-microbiat agent 200.00 SF 0.00 0.18 36.00
5. Dehumidifier(per 24 hour period)- 12.00 EA 0.00 101.25 1,215.00
XLarge-No monitoring
Two extra large dehumifiers for six days to dry Class 4 materials(plaster)
6. Air mover(per 24 hour period)-No 12.00 EA 0.00 25.00 300.00
monitoring
Two air movers for six days to dry class 4 materials(plaster)
7. Equipment setup,take down,and 10.00 HR 0.00 44.29 442.90
monitoring(hourly charge)
Total: SPRINGER# 2,224.81
Line Item Totals:SPRINGER# 2,224.81
SPRINGER# 'I/18/2013 Page:2
�ESr�I Restoration Professionals
505 Minnehaha Ave.W.
Saint Paul,MN 55103
Phone:(651)379-1990
Fa�c:(651)379-1991
License#BC396147
Summary
Line Item Total 2,224.81
Cleaning Sales Tax @ 7.625% 169.66
Replacement Cost Value $2,394.47
Net Claim $2,394.47
Rich Hilmanowski
,
SPRINGER# 7/18/2013 Page:3
. ����'- 1 y �(�
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CUTS CUSTOM CONSTRClCTION/NC.
I.tC:�C173484
Date 7/'17N3
BID
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�g�a on:$78 e�st 7'"street ST. Paul MN.55106 '
,C�.Springer collec�ions `
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Bid Sammary: _
-Repair walls and csitings in basement
-Replace Z new bath veMs in bathrooms.
-Re�saith+epiace tile irt hallwar ?
-ln�a!!new vanity in me�s bathroom
-Paint haliway and bathrooms
• rotei $�s,�ao �
�8,2so�own$825o due open completion
Prics inciudes mateNal and labor '
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All materlal ar�d labor is wamnted tu manufacture specffications:
L_.
Autho�ed signature of Acceptance: Da#e;
C�tom Cuts ConstruGtioe�: Dat�e:
Joe HoMrard 659-2l0-0183 Kelly Naugle 612-F,88-+1558
08108/2013 1@:53 6517973416 LUX Y REMODELING PAGE 01/01
�c Vl i h SiC� �U�SS
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�� �,j 1!. -1t'.� �� i S VVlai �,v� ��c�v'esS
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� � .Luxuty Bath of the �vin eities .
������ 245 Roselawn Ave#35
Maplewood, NIN 55117 �
������z-��� � ��'�'�� 651-334-6414 fax 651-797-3416
Invoice � '
Customer
Name Springer Collec6ons(Steve Hannig) pate 817J20'!3
Address 878 7th St E Room#
Ciry St Paul Stats MN ZIP 55'106 Rep Ken Audetbe �
Phone FOB —._..� _......
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Desc " 'on Unit Pricw _ TQTAL
1 B riemo and BrsposaJ of existing walJs and ffoor $95.04 $1,5�p.0�
18 Framing new walls(indudes prep,plumblrtg, etecfrical} $95 44 $1,7'!0.00
9TQ sq ff dryw�ll, mud� #ape, sand{tnaterla!end Labor} $24_AD $4,08Q.00 �
l81 Sq f�new tile floor(material allawance$4✓sq tt) $220fl 53,982.00
170 sq fr paint(prime and pairtt spaceJ $5.85 $894.50
100 knock down mafer/af on waNs $14.50 $1,450A0
2 24"Vanify wiffr 1op and fau�ets{moen branciford ahrome) $560.00 $i,120.00
I 2 repairc�utside wa1ls on faunda�on $675.00 �1,350.00
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� SubTotai $1fi,208.60� f
� Payment DetaEls Shlpping&Handling $0.00
� Q Gash � - Taxes � Sfate -
�p chec�c � _y � .
Q Credit Card TOTAL. $i6 206.50. �II
Name
CC#..�..�.�. .....,__�.
� Expires