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Biga, Richard NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota Minnesota State Statute 466.05 states that “…every person…who claims damages from any municipality…shall cause to be presented to the governing body of the municipality within 180 days aer the alleged loss or injury is discovered a noce stang the me, place, and circumstances thereof, and the amount of compensaon or other relief demanded.” Please complete this form in its enrety by clearly typing or prinng your answers to each queson. If you have addional documentaon, you may add those documents to your submission. You will not be contacted by telephone unless clarificaon is needed. The claim process for invesgaons can take upwards of four (4) weeks. This form must be signed, dated with all applicable secons completed. Submission this completed form to the Saint Paul City Clerk’s Office by email (cityclerk@ci.stpaul.mn.us), fax (651-266-8574) or mail addressed to “Saint Paul City Clerk, 15 West Kellogg Blvd., Suite 310, Saint Paul, MN 55102”. Claimant: First Name: ___ Richard / Michelle ________________ Last Name: ______ Biga / Curci ____________________ Please Indicate Your Pronouns: ☐ She/Her/Hers, ☑ He/Him/His, ☐ They/ Them/Theirs Company or Business Name: ___N/A_____________________________________________________________________________ Is this claim being made by an Insurance Company? YES / NO If yes, what is your Claim/File Number? _ NO _____________________ Is this claim being made by an Aorney? YES / NO If yes, what is your File Number? ___ NO _________________________________ If yes, provide your Insured’s/ Client’s Name: _______________________________________________________________________ Street Address: _ 1774 Upper Aon Rd __________________________________________________________________________ City: ___ St Paul ____________________________________ State: ___ MN ___________________ Zip Code: __ 55106 ____________ Dayme/Work Phone: ____ 612-568-2442 ___________________ Cell Phone: __ 612-568-2442 _______________________________ Date of Incident or Date Discovered (Must Complete): ___ Sept 28, 2023 ___________ Time: ___ ~8:00PM ___________________ Please state, in detail, what happened that prompted you to file a Noce of Claim Form: The homeowners (Richard Biga and Michelle Curci) first discovered the failure on Sept 28, 2023 when a home inspection report with sewer video was obtained by the homeowners. Please state why or how you feel the City of Saint Paul is responsible for your Damages? The failed repair was completed by Palda and Sons at or around the time of 09/10/2012 as part of homeowner funded special assessment work completed on behalf of the City of Saint Paul for the homeowner. The failed repair is evidenced in the Inspection Services video at 70’ 8” at the offset caused by a dual coupling failure where the original house line meets the repaired PVC and a major offset caused by a failed coupling failure at 77’ 9” where the repaired PVC meets to Sewer Main. This failed repair exists entirely under White Bear Ave. Due to the nature and the location failure the homeowners along with 3 contractor experts in the area believe the failure was caused by improper backfill and compaction of the substrate leading to excessive settling and the dropped connection. This failure at both couplings on the repair work led to an obstructed sewer pipe which needed to be repaired. Repair was completed at homeowners expense by Commercial Utilities, Inc. on 10/17/23 at a cost of $7914. The correction of the failed repair work was completed with code appropriate Fernco fittings. Inspection Video https://youtu.be/VLFReNJo1Tw Please check the reason that most closely describes the reason for your subming a claim. Please note the documents that will need to be provided with your completed form. Photographs will be accepted. All documents submied become the property of the City of Saint Paul and shall not be returned. ☐ Automobile damage from a motor vehicle accident: please provide two esmates for repairs or actual bill that has been paid. Revised March 2023 ☐ Automobile damage from a street defect or pothole: please provide two esmates for repairs or actual bill that has been paid. ☐ Automobile was towed and may or may not have sustained damage: please provide copy of towing cket (if available), receipt from Impound Lot, and two esmates for repairs or actual bill that has been paid. ☐ Snow Emergency: please provide copy of towing cket (if available), receipt from Impound Lot, and two esmates for repairs or actual bill that has been paid. ☑ Property damage: please provide two esmates for repairs or actual bill that has been paid. ☐ You were injured during a motor vehicle accident: please provide police report number, details about injury. ☐ You were injured in the City of Saint Paul: please provide police report number, witnesses, and details about injury. Connue to page 2 of Noce of Claim Form. Failure to complete and return both pages will result in delays. This secon must be completed for all claims. Is there a police report for this incident? NO If yes, please provide the police report case number: ___________________________ If yes, what law enforcement agency responded? ____________________________________________________________ Where did the incident take place? Please provide a street address, intersecon or name of city park or facility: ____________________________________________________________________________________________________________ What would you like to see happen to resolve this claim to your sasfacon? _____ Full reimbursement of repair to the sewer line cost _____________________________________________________________ Were there witnesses to this incident? Please provide names and contact phone numbers: _____ Tony Curella 651-226-6891 _______________________________________________________________________________ For property damage claims, including vehicle accidents. Your vehicle’s informaon: Year: _________ Make: _________________ Model: __________________ Color: __________________ License Plate #: _________________________ State vehicle is registered in: ___________________________ Registered owner of vehicle: _____________________________ Driver: __________________________________________ Area(s) damaged:______________________________________________________________________________________ If a City vehicle was involved, License Plate #: _________________________________ Color: _______________________________ Was there City insignia on the vehicle? YES / NO Driver’s Name: ______________________________________________________ Other property damaged: __ Sewer Line __________________________________________________________________________ For injury claims of any type. What part of your body was injured? ____ N/A _____________________________________________________________________ Did you go to the emergency room or urgent care? YES / NO Where? ___________________________________________________ Was medical treatment received? YES / NO Where? ________________________________________________________________ First day of medical treatment? _____________ Are you sll receiving medical treatment? YES / NO Revised March 2023 Revised March 2023