Claim, Northhouse, TheressaCLAIM 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: Theressa Northouse
2. Address: 1599 Washington, Duybuque, IA 52001
3. Telephone Number: 563 582 9355
4. Date of Incident: 10 8 01
5. Time of Incident: Around 6 p.m.
6. Location of Incident (Be specific): 15th & 16th St. Sewage pipes were clogged in the alley.
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.)
Sewage backup into our basement. We called plumber (5:15 P.M.) thought the clog was our (it wasn't). WE called City that morning (7:30 A.M.)
and asked them to check the lines. They didn't.
8. What were weather conditions like? Chilly - clear
9. Give name and address of any witnesses: Myself & my husband (Jim Northouse) same address
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.)
Small portion of rug - sewage water. We removed that piece of rug.
13. What other damages do you claim, if any?
Cost of plumber
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?
$84.80
16. Why do you claim the City of Dubuque is responsible?
They failed to check their sewer lines when we called and requested them to do so. If they had, we wouldn't have called the plumber or got
sewage in basement.
17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name and address.)
No
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 11th day of October , 2001. .
/s/ Theressa Northouse
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
CLAIM 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. 13~ 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:-"~ ~t~(~ ~
2. Address:
3. Telephone Number: ~_~_~.'~
4. Date of Incident:
5. Time of Incident: ~.~
6. Location of Incident (Be specific):
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
8. What were weather conditions like?
name and address of any witnesses.-
10. Did police investigate? (If so, give names of officers.)
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
Y~O
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.)
13. What other damages do you claim, ifany? Q_C-~4 d~ ~:~lOna~_~/~
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.)
15. What amount do you claim from the City of Dubuque?
16. Why do you claim the City of Dubuque is responsible? -~-~u ~o,I le~ -~ r-J~c ~
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 (~)~- ~'~ ]c~r~ , 20 ~/.
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
Jaeger
PLUMBING & PUMP, ~NC.
17448 S. John Deere Rd.
Dubuque, lA 52001
Phone(319)583-6677
Fax (319) 583-5495
INVOICE
DATE INVOICE #
11/5/2001 5233
BILL TO:
Jim No~hous
1599Washington
Dubuque, lA 52001
QUANTITY DESCRIPTION
2
L;redit acc(
(90) days,
RO. NUMBER TERMS PROJECT
10/08/01
Due on receipt
Labor
Sales Tax
unts are clue on the 1st ot the month, r~ax~mum credit
1/2% service charge on all past due accounts.
RATE AMOUNT
40.00 80.00T
8.00% 4.80
TOTAL $84.80