Claim, Shopko Str #164CLAIM AGAINST THE CITY OF DUBUQUE, IOWA
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 W. 13th St., Dubuque, IA 52001. 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 Council. 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 THE AUTHORITY TO MAKE ANY REPRESENTATION TO YOU AS TO WHETHER YOUR CLAIM WILL OR WILL NOT BE PAID.
1. Name of Claimant: Shopko Str. #164
2. Address: 255 JFK Rd
3. Telephone Number: 583 5762
4. Date of Incident: 7 5 01
5. Time of Incident: 8:00 - 9:00 p.m.
6. Location of Incident (Be specific): 255 JFK Rd. - Front Maintance & Front Fitting Rooms
7. DESCRIBE ACCIDENT OR OCCURRENCE THAT CAUSED INJURY OR DAMAGE. (Give full details upon which you base your claim. If a City employee was involved, give the employee's name.)
Sewer lines were plugged, backup was comming through our lines in doors of the store.
The lines had to be unplugged and suctioned. Carpets need to be extracted in cleaned in men's fitting rooms.
8. What were weather conditions like? Dry
9. Give name and address of any witnesses: Tori Anderson & Jean Redmond
10. Did police investigate? (If so, give names of officers.) No
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
No
12. Was any damage done to property? (If so, describe property and the extent of damages. Attach estimates of damages or describe basis for ascertaining extent of damage.)
Cleaning of carpets and floors
13. What other damages do you claim, if any?
Root Bill of $770.60? for cleaning city sewer linees; see attachment
14. Have you been compensated for any part or all of your claim by any insurance company? (If so, give name and address of insurance company and amount paid.)
No
15. What amount do you claim from the City of Dubuque?
$770.60 plumbing, $85.00 dumping fees and carpet cleaning which bills are pending.
16. Why do you claim the City of Dubuque is responsible?
Statement that this plugged sewer lines was pre existing due to the House of China situation and city responsible due to plugged sewers.
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 answer to Question 17 is yes, have you received any payment from that source, and if so, in what amount?
Dated at Dubuque, Iowa this day of , 20 .
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
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 Council. You will be
p~ovided with a copy of that report and recommendation.
Tk~E FINAL DECISION ON ALL CLAIMS IS MADE BY THE CIT~ COUNCIL.
NO E~PLOYEE OF TH~ CITY OF DUBUQUE HAS THE AUTHORITY TO MAKE ANY
REPRESENTATION TO YOUAS TO WH~'£~R YOUR CLAtM WILL OR WILL NOT BE
1. Na~e of Claimant:
2. Address: 25~
3. Telephon.e ~m~er=
Date of Incident:
5'. Time of Incident:
t0.
11.
Location of incident. (Be specific) .
DESCRIBE 'ACCIDENT OR OCCURRENCE THAT CAUSED IN~ u~y OR DA/6AGE.
(~ive full details upon which you base your claim, r~,f a City
employee was involved, give the employee,s name.)
wnac were weather condatlons llke? '~,~ .
Give name and address of any witnesses.
Did police investigate? (If so, give names of
Was anyone injured?
injuries.)
(If so, ~ive
address an~ ~._te~ o~
12.
Was any damage done to property? (If so, describe property
and tt~e extent of dalaage. Attach estimates of da~a~es or
describe basis for ascertaining extent of dal~a~e.)
13. What other d~ges do you claim, if any?
~oc4-e,: ~I o4- ~rb,9,~° &or a[~'~ c~ s~,~ h~.~ ~.
~4. ~ve yo~ bee~ compensated for a~y p~rt or all of your ola~ by
~y insur~ce company? (If so, ~ive n~e ~d address of
insur~ce co~y and ~o~t paid.)
15. What azaoullt do you clai~ from the 'City of Dubuque?
t6. ~y do you cla~ ~e City of D~u~e is responsible?
17. Have you ~de ~y cia~ a~ainst ~yone else for d~es as a
result of this incident? ~ e
If yes, give name and address:
18. If the answer to 'Question 17 is yes, have you received any
payment from that source, and if sO, in what a~ount?
Dated ~t Dubuque, Iowa, this day of
2001.
(Si~lature)
(Print N~me)
(Revised January, 2000)
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M & M SEPTIC TANK SRV,
11865 J.F.K. RD,
DUBUQUE IA ~2002
Phone: 319-556-6328
Date: 7/6/01
Invoice Number: 381
PO Number:
Due Dale: 7/'6/01
Billing Terms: On Receipt
SHOPKO STORES
255 ]OHN F. KENNEDY RD.
DUBUQUE IA
52O01
85.00
2% I~fS1- ~- I ~ 30 DAYS.
SubTobl: 85.00
Tax: 0.00
Total: 85.00