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Williams, RobertNOTICE 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 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 answers to each question. If you have additional documentation you may add those documents to your submission. You will not be contacted by telephone unless clarification is needed. The claim process for investigations can take upwards of four (4) weeks. This form must be signed, dated with all applicable sections completed. Submission is to the Saint Paul City Clerk’s Office. You may email, fax (651-266-8574) or mail the form. Mailing address is “Saint Paul City Clerk, 15 West Kellogg Blvd., Suite 310, Saint Paul, MN 55102” Individuals: First Name _____Robert________________ Last Name _________Williams_______________________ Please Indicate Your Pronouns: She/ Her/Hers ☐ He/Him/His ☒_ They/ Them/Theirs ☐ Company or Business Name: ____The Huntington Condominiums ________________________________ Is this claim being made by an Insurance Company? If yes, what is your Claim/File Number?: ________N/A______ Is this claim being made by an Attorney? NO If yes, what is your File Number? _______________________________ If yes, then provide your Insured’s/ Client’s Name ____________________________________________________________ Street Address: _________________________________________________________________________________________ City: ____________________________________________ State ___________________ Zip Code __________________ Daytime/Work Phone _______________________________ Cell Phone ____________________________________________ Date of Incident or Date Discovered (Must complete) ______See attached___________Time _________________________ Please state, in detail, what happened that prompted you to file a Notice of Claim Form. ____See attached_____________ Please state why or how you feel the City of Saint Paul is responsible for your Damages? ___See attached_______________ Please check the reason that most closely describes the reason for your submitting a claim. Please note the documents that will need to be provided with your completed form. Photographs will be accepted. All documents submitted become the property of the City of Saint Paul and shall not be returned. ☐ Automobile damage from a motor vehicle accident: please provide two estimates for repairs or actual bill that has been paid. ☐ Automobile damage from a street defect or pothole : please provide two estimates 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 ticket (if available), receipt from Impound Lot, and two estimates for repairs or actual bill that has been paid. ☐ Snow Emergency: please provide copy of towing ticket (if available), receipt from Impound Lot, and two estimates for repairs or actual bill that has been paid. ☐ Property damage: please provide two estimates 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. This section must be completed for all claims. Is there a police report for this incident? Yes No If yes, please provide the police report case number ______N/A___________ Revised December 2021 If yes, what law enforcement agency responded? _______________________________________________________ Where did the incident take place? Please provide a street address, intersection or name of City park or facility. ________________________________________________________________________________________________________ Notice of Claim Form, page two. Failure to complete and return both pages will result in delays. What would you like to see happen to resolve this claim to your satisfaction? $10,200 Reimbursement for waterline replacement._ Were there witnesses to this incident? Please provide names and contact phone numbers. _Tom Zangs, Plumbing Inspector 651-775-3183 cell, 651-266-6277 phone._ For property damage claims, including vehicle accidents. Your vehicle’s information: 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: ___________________________________________________________________________________ For injury claims of any type. What part of your body was injured? __________________________________________________________________________ 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 still receiving medical treatment? Yes No Did you miss any work as result of this incident? Yes No Employer(s) _______________________________________________ How much time have you missed from work?___________________________________________________________________ If you are submitting other documents, please state what you are attaching and how many pages. ______________________ By signing this form, you agree that all information provided is true and correct to the best of your knowledge. Please NOTE that submitting a false or misleading claim can and will result in prosecution under Minnesota Statutes. Name of Person completing form: ___Robert H. Williams_______________________________ Signature of Person submitting this form: _______________________________________________________________________ Relationship of person signing to Party making the claim: ___Condo Association, Treasurer______________ Date document is being signed 3/21/2025 Revised December 2021 NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota ATTACHMENT CLAIM FOR REIMBURSEMENT UNDER SPRWS LEAD-FREE PROGRAM The following is additional information related to the attached claim form: Date of Incident or Date Discovered: March 13, 2025, beginning around 9:15am A unit owner in the Huntington Condominiums located at 300 Marshall Avenue in Saint Paul, discovered water coming through the basement slab. They had Master Plumbing of Inver Grove Heights, Minnesota investigate the source of the water. The plumber exposed the pipe and discovered leaks in the elbow of mainline where it bends to go up to the water meter. Tom Zangs, Plumbing Inspector, came to the building to review the situation. He determined that the waterline to the water cut-oƯ in the boulevard needed to be replaced. He thought that because the existing line was galvanized steel, it would be eligible for the Lead-Free Replacement Program administered by Saint Paul Regional Water Services (SPRWS). Graeme Chaple, Distribution Division Manager, informed Illona LaDouceur that the leak investigation stated this event would be part of the Lead-Free Replacement Program and to get information from Tom Zangs and Scott Anderson. Tom Zang forwarded the contact information for the condo association: Primary Contact: Rob Williams, Association Treasurer Unit 2 612-790-1814 cell RobertHWilliams1958@gmail.com. Contact for Access to Unit where work would be done: Evan Carothers Unit 7 715-220-7497 evan.carothers@gmail.com . Ilona LaDouceur contacted Rob Williams to do the Intent Form over the phone and then told him that she would email the agreement for signature. During preparation of the agreement Kathy told her that it had been determined this property “No longer met the criteria” for the program. Ilona was told that Tom Zangs would again contact Rob of this and that Rob would need to contact a private contractor to make the replacement. After securing three bids, the condominium association contracted with M&B Services, Inc. to complete the replacement. On the morning of March 20, M&B completed the work. That same day Graeme Chaple and Brent Marsolek, Project Manager, informed the Lead- Free Coordinator that it was a bad/negligent decision to not do the replacement as Rob had been informed earlier that the “galvanized steel falls under the lead category”. He asked Ilona to call Rob and restart the replacement process. She called Tom Zangs, who informed her that M&B Services had just finished the work moments before. Brent Marsolek had Rich Rowland, Business Division Manager, confirm reimbursement for the work because of negligence. Ilona called Rob and informed him that the SPRWS would reimburse the condominium association for the work. She would send him the paperwork needed for reimbursement. We are sending the attached claim form, this attachment, and the invoice/receipt from M&B Services, Inc. to process a reimbursement in the amount of $10,200 to the Huntington Condominiums. Thank you for your consideration, Rob Williams, Association Treasurer 612-790-1814 INVOICE M&B Services Inc 27498 Olinda Trl Lindstrom, MN 55045 molly@mb-servicesllc.com +1 (651) 248-1725 www.mb-servicesllc.com Bill to Robert Williams 300 Marshall Ave St. Paul, MN 715-220-7497 Ship to Robert Williams Invoice details Invoice no.: 1613 Terms: Net 10 Invoice date: 03/20/2025 Due date: 03/30/2025 #Date Product or service Description Qty Rate Amount 1.03/20/2025 Water Break hole in basement floor at front closet. Excavate in blvd. Bore new 1" copper water service from basement to blvd. Connect to existing curb stop. More meter into front closet. Cut open wall where existing water meter is. Grab existing plumbing and fun into front closet and connect to meter set. Patch floor with concrete. 1 $10,200.00 $10,200.00 2.Permit and Inspection Fees Includes all permit and inspection fees.1 $0.00 $0.00 Total $10,200.00 Payment -$10,200.00 Balance due $0.00 Paid in Full