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Claim by Jim DavidCLAIM 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 West 13th St., Dubuque, IA 52001. It will then be referred to the appropriate department for investigation and to the City~Attorney's Office. 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. I ~~ . ~b . ~,.,, t ~~ ~ ~ ~ . 1. Name of Claimant. 2. Address: ~l i` 3. Telephone Number => (~ ~' ~ ~ ~ ~ U ~ 3 4. Date of Incident: ~~_~ ~' - ~`^z~ - 5. Time of Incident: ~~la. ~ ~'U t ~~~ 6. L-o~cation of Incidennt (Be s ecific !7~ S~' 1M P i'1 mod' .- ~ LS " ~ ~ - 7. Describe the accident or occurrence that caused injury or damage. (Give full details upon which you bast your claim. If a City employee was involved, give tl~~ employee's name.) ~ / ..., 8. What were weather c1on/ditio/ns like? n ~V 9. Give name and address of any witnesses: - ,~«~ ~~; w ~~ ~ , -- - _ri >' ~ '~. 10. Did police investigate? (If so, give names of officers.) 11. Was an~rone injured? (If so, give names, addresses, and extent of injuries). 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.) ~ 2 _ ~ [f'l > ~ ..L.. ~~~ ~OC< :~c° !' yti~ ry ~ :-,. ~, J P hG c',ti -~- ~ ~ .Oi' ~'1 G /C'^~ C' 13. What other4d:-amages do you claim, if any? ~~-L~.ri.Yl t/-~~1 'inn ~ CJ ~til C r,~~ C ~~~;C~C~'~ ~ l; S S .~1- ~r ` ~~ S 4dr~ ~`.. F n c l ~ "1- l .~ ~ Oi ` ~ /~ '`I- ~ f ~l CG ~~ ~~ Q ~ / ld ' .~ ~ t?'dt I'f ~ . 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.) - 1`,-~* 15. What amount do you claim from the City of Dubuque? ~ lv+~ 5 ~~,C ao `,^1 ~~62z, ~ / c~~ 7" t ("i ©r'! C/; ~ ~-- Mn M n ~C~n r~ v~ /I O /1 :. ,~ . f") ~ ~ ~ C~ Y~ ~- C°Q Y~7 Q Y~ L ~ Z 16. Whv do you claim the Citv of Dubuaue is resaonsible? 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 this day of ~~~ ~. Prr~ ~ ~~ _ , 20 ®`~ . '~1 .~' (Suture) ~ti y~l 1 ,~ ~ iJ i (Print Name) PROPOSAL KEN KENNEDY 2944 Washington -Dubuque, IA ~ 563-599-3578 DATE: 12-22-2008 SUBMITTED TO: JIM DAVID STREET ADDRESS: 2824 WASHINGTON ST. CITY, STATE, ZIP: Dubuque, IA 52001 SPECIFICATIONS AND ESTIMATES FOR: Tear up 594 sq. ft. VCT the (2 men, 4 hows @ $25 per how per man). $ 200.00 Install 12 x 33 carpet (44 sq. yds. @ $5.00 per yard) $ 220.00 Steps. $ 50.00 Floor prep and fill floors (Labor = $100; Materials = $200) $ 300.00 Instal1243 sq. ft. VCT the @ .90 per sq. ft. $ 218.70 Move & replace 2 appliances @ $25 each. $ 50.00 Pull and reset stool. $ 75.00 12 x 33 (44 sq. yds. Carpet @ $16.00 per yard). $ 704.00 270 sq. ft. VCT the (6 boxes @ $35.00 per box). $ Z 10.00 Fwnish material and labor, complete in accordance with above specifications, for the sum of Two Thousand Twenty Seven Dollars and Seventy Cents ($ 2,027.70) AUTHORIZED SIGNATURE: Note: This proposal may be withdrawn by us if not accepted within 10 ten days. All material is guaranteed to be as specified. All work to be completed in a workmanlike manner according to standard practices. Any alteration or deviation from above specifications involving extra costs will be executed only upon written orders, and will become an extra charge over and above the estimate. All agreements contingent upon strikes, accidents or delays beyond our control. ACCEPTANCE OF PROPOSAL -The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Payment will be made as outlined above. DATE OF ACCEPTANCE: Signature: Signature: