Claim, Eisbach, Peter J.CLAIM AGAINST THE CITY OF
DUBUQUE
This written report constitutes your claim against the City of
Dubuque, Iowa. You should complete this form in full and attach
any additional information that supports your claim.
The Claim must be filed with the City Clerk at City Hall, 50
West 13th Street, Dubuque, Iowa 52001-4864. It will then be
referred by the City Council to the appropriate Department for
investigation. Once that investigation is completed, a report and
recommendation will be submitted to the City Councii. You will be
provided with a copy of that report and recommendation.
THE FINAL DECISION ON ALL CLAIMS IS MADE BY THE CITY COUNCIL.
NO EMPLOYEE OF THE CITY OF DUBUQUE HAS T~ AUTHORITY TO MAKE ANY
REPRESENTATION TO YOU AS TO Wn~THER YOUR CLAIM WILL OR WILL NOT BE
PAID.
1. Name of Claimant: Peter J. Eisbach
2. Address: 780 West Locust, Dubuque, IA 52001
3. Telephone Number: 563-556-3073:
4. Date of Incident: 4-9-01
5o Time of Incident: 5:00 A.M.
6. Location of incident. (Be specific)
780 West Locust, basement, Dubuque, IA 52001
7.DESCRIBE ACCIDENT OR OCCURRENCE THAT~USED INJURY OR DAMAGE.
(Give full details upon which youbase your claim. If a City
City Sewer in front of our home became blocked after rain in early morning hours of 4/9/01 and water, sewage,
and mud backed up in our basement.
8. Weather: rainy
9. Witnesses: Dubuque City employees and maintenance workers.
10. Police investigate: No.
11. Anyone injured: No.
12. Damage done to property: Loss of basement carpet, lineoleum, drywall, camping
supplies, misc., lumber and construction items, box of college textbooks, misc. personal items,
basket of laundry.
13. Other damages: Rental of industrial fans to dry basement, water to hose basement,
electricity to run equipment.
14. Other compensation: No.
15. Amount claimed from City: (itemized on other side) $656.28
16. Why City is responsible: This is second time water has backed up from the sewer (also June 1999)
Water backed up from City sewer causing damage to our property.
17. Any claim made to anyone else? No.
Dated at Dubuque, Iowa this 22nd day of April, 2001.
/s/ Peter J. Eisbach
13.
14.
Was any d~mage done to property? (If so, describe p~operty
and the extent of damage. Attach estimates of damages or
describe basis for ascertaining extent' of damage.)
What other dsunages do you claim, if any? ~ ~ ~ ~
Have you been compensated for any part or all of yo~ur claim by
any insurance company? (If so, give name and address of
insurance company and amount paid.)
15. What amou/at do you claim from the City of Dubuque?
16. why do you claim the City of Dubuque is responsible?
17. Have you made any claim against anyone else for damages as a
result of this incident? ~
If yes, give name and address:
18. If the ~--~swer to Question 17 is yes, have you received any
payment, from that source, and if so, in what amount?
Dated at Dubuque, Iowa, this
2001.
day of
~-~i~natur e )
(Print Name)
(Revised January, 2000)
DAISY FRESH ~ CLEANING
CARPET CLEANERS
~o,,,,,,~,,~.,,,.,~ WORK
Carnet ~ & Fum~ure C~:ming
0uB~v~,~w~ ~, ORDER
(319) 5~31~ or ~-3796