Claim by Mark Sarazin 2 11 09~ + r
r
IAA A T U TJ A .
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.
1. Name of Claimant: ~` ;%j~r i~~~', ..~ ~'r f~G ~ ~~°~
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2. Address Eq~ > ~, r> l-~~f. ~ r,°'~ 5 /< : ~ f ,
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3. Telephone Number ~'"~ ;~~'. ~; 1 ~~'
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4. Date of Incident; ~ ~~ ,, ~w~ r;~. ~ ~I
5. Time of Incident: C~ ~-~'~' ~~~~~
6. Location of Incident (B,e specific):
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7. Describe the 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.)
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8. What were weather conditions like?
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9. Give name and address of any_witnesses - _
10. Did police investigate? (If so, give names of officers.)
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11. Was anyone 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.)
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13. Wff hat other damages do you claim, if any? //
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14.. Have you been compensated for any part or all of your claim by any
insurance company? (If s4, give name and address of insurance company and
amount paid.)
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15. What amount do you claim from the City of Dubuque?
Q ~ //r_a .547/J'
16. Why do you claim the City of Dubuque is responsible?
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17. Have you made any claim against anyone else for damages as a result of
this incident? (If yes, give name and address.)
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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 ~ ~ (~
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~ervicetnaster of the Key City
1845 Washington St. {563}557-1488
Dubuque IA 52001 Fax:{563}557-2507
Fed ID # 421429160
Insured: Mark Sarazin
Property: 2330 Hempstead St.
Dubuque, IA 52001
Claim Number:
Coverage
Dwelling
Other Structures
Contents
Date Contacted: 1/26/2009 1:30 PM
Date of Loss: 1/26/2009
Date Inspected: 1/26/2009 2:00 PM
Home: (563) 582-6147
Cellular: (563) 564-2608
Policy Number: Type of Loss: Sewage
Deductible Policy Limif
$0.00 $0.00
$0.00 $0.00
$0.00 $0.00
Date Received: 1/26/2009 2:00 PM
Date Entered: 1/30/2009 9:35 AM
Price List: IADUSB 15AUG08
Restoration/Servi ce/Remodel
Estimate: SARAZIN
~ervicemaster of the Key City
1845 Washington St. {563}557-1488
Dubuque IA 52001 Fax:{563}557-2507
Fed ID # 421429160
SARAZIN
Main Level
Main Level
DESCRIPTION QUANTITY UNIT COST RCV DEPREC. ACV
Emergency service call -during 1.00 EA 101.18 101.18 (0.00) 101.18
business hours
Equipment setup, take down, and 4.00 HR 35.69 142.76 (0.00) 142.76
monitoring (hourly charge)
Equipment decontamination charge - 3.OOEA 36.53 109.59 (0.00) 109.59
HVY, per piece of equip
Add for personal protective 12.00 EA 15.03 180.36 (0.00) 180.36
equipment -Heavy duty
Dumpster load -Approx. 30 yards, 5- 1.00 EA 407.23 407.23 (0.00) 407.23
7 tons of debris
Floor protection -self-adhesive 180.00 SF 0.45 81.00 (0.00) 81.00
plastic film
Total: Main Level 1,022.12 0.00 1,022.12
`` - ~~
-~
STORAGE
r- -~1 Ceiling H eight: 8'
636.00 SF Walls 305.56 SF Ceiling
~r,,,,g.F, { ~ 941.56 SF Walls & Ceiling 305.56 SF Floor
~ ~~ ~
' T ~~ 33.95 SY Flooring 79.50 LF Floor Perimeter
II _ < < ~,
~, 79.50 LF Ceil. Perim eter
DESCRIPTION QUANTITY UNIT COST RCV DEPREC. ACV
Apply anti-microbial agent 305.56 SF 0.17 51.95 (0.00) 51.95
Water extraction from floor - 305.56 SF 1.10 336.12 (0.00) 336.12
Category 3 water -Heavy
Clean the floor with pressure steam 305.56 SF 0.61 186.39 (0.00) 186.39
Clean the surface area with pressure 319.20 SF 0.61 194.71 (0.00) 194.71
steam (walls)*
Tear out and bag wet insulation 159.60 SF 0.39 62.24 (0.00) 62.24
Cleaning & Remediation - 4.00 HR 37.94 151.76 (0.00) 151.76
Supervisory -per hr
Air mover (per 24 hour period) - 2 x 3 6.00 EA 26.23 157.38 (0.00) 157.38
days*
Dehumidifier (per 24 hour period) - 3.00 EA 70.08 210.24 (0.00) 210.24
Large - 1 x 3 days*
Content Manipulation charge -per 12.00 HR 29.71 356.52 (0.00) 356.52
hour
Power distribution box x 3 days* 3.00 DA 27.50 82.50 (0.00) 82.50
SARAZIN 2/4/2009 Page:2
~ervicemaster of the Key City
1845 Washington St. {563}557-1488
Dubuque IA 52001 Fax:{563}557-2507
Fed ID # 421429160
CONTINUED -STORAGE
DESCRIPTION QUANTITY UNIT COST RCV DEPREC. ACV
Electrical repair -Minimum charge 1.00 EA 155.00 155.00 (0.00) 155.00
Totals: STORAGE 1,944.81 0.00 1,944.81
BEDROOM
52'6"1-6'91"- Ceiling Height: 8'
~"' 317.33 SF Walls 98.33 SF Ceiling
415.67 SF Walls & Ceiling 98.33 SF Floor
BFONLbY. O O
10.93 SY Flooring
39.67 LF Floor Perimeter
goo„ 39.67 LF Ceil. Perim eter
10' 4" -
DESCRIPTION QUANTITY UNIT COST RCV DEPREC. ACV
Apply anti-microbial agent 98.33 SF 0.17 16.72 (0.00) 16.72
Water extraction from floor - 98.33 SF 1.10 108.16 (0.00) 108.16
Category 3 water -Heavy
Clean the floor with pressure steam 98.33 SF 0.61 59.98 (0.00) 59.98
Clean the surface area with pressure 116.40 SF 0.61 71.00 (0.00) 71.00
stea(walls)*
Tear out wet paneling, bag for 317.33 SF 0.33 104.72 (0.00) 104.72
disposal
Tear out and bag wet insulation 76.40 SF 0.39 29.80 (0.00) 29.80
Tear out wet drywall, cleanup, bag for 36.40 SF 0.55 20.02 (0.00) 20.02
disposal
Tear out trim/base and bag for 14.00 LF 0.51 7.14 (0.00) 7.14
disposal
Air mover (per 24 hour period) - 1 x 3 3.00 EA 26.23 78.69 (0.00) 78.69
days*
R&R Outlet 2.OOEA 12.36 24.72 (0.00) 24.72
Totals: BEDROOM 520.95 0.00 520.95
SARAZIN 2/4/2009 Page:3
Servicemaster of the Key City
1845 Washington St. {563}557-1488
Dubuque IA 5200] Fax:{563}557-2507
Fed ID # 421429160
r~_~.
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s
Missing Wall:
LAUNDRY
441.33 SF Walls
604.42 SF Walls & Ceiling
18.12 SY Flooring
55.17 LF Ceil. Perimeter
1- 2'8" X 0'0" Opens into HALL
Ceiling Height: 8'
163.08 SF Ceiling
163.08 SF Floor
55.17 LF Floor Perimeter
Goes to Floor/Ceiling
DESCRIPTION QUANTITY UNIT COST RCV DEPREC. ACV
Apply anti-microbial agent 163.08 SF 0.17 27.72 (0.00) 27.72
Water extraction from floor - 163.08 SF 1.10 179.39 (0.00) 179.39
Category 3 water -Heavy
Remove Dryer -Gas -Standard grade 1.00 EA 17.17 17.17 (0.00) 17.17
Includes: Labor cost to remove a gas cl othes dryer and to discard in a job-site was te receptacle.
No life expectancy data
Freezer -Remove and Dispose* 1.00 EA 26.82 26.82 (0.00) 26.82
Clean the floor with pressure steam 163.08 SF 0.61 99.48 (0.00) 99.48
Clean the surface area with pressure 220.68 SF 0.61 134.61 (0.00) 134.61
steam (walls)*
Tear out wet drywall, cleanup, bag for 36.40 SF 0.55 20.02 (0.00) 20.02
disposal
Plastic bag -used for disposal of 20.00 EA 2.18 43.60 (0.00) 43.60
contaminated items
Dehumidifier (per 24 hour period) - 3.00 EA 70.08 210.24 (0.00) 210.24
Large - 1 x 3 days*
Air mover (per 24 hour period) - 1 x 3 3.00 EA 26.23 78.69 (0.00) 78.69
days*
Plumber - (PER BID MR ROOTER) 1.00 HR 1,498.58 1,498.58 (0.00) 1,498.58
Remove and replace 50 gal. Rheem
electric water heater and Hydro
Scrub sewer lines*
R&R 220 volt outlet -Heavy duty 1.00 EA 34.49 34.49 (0.00) 34.49
R&R Temporary power -hookup 1.00 EA 289.69 289.69 (0.00) 289.69
R&R Outlet 3.00 EA 12.36 37.08 (0.00) 37.08
Totals: LAUNDRY 2,697.58 0.00 2,697.58
SARAZIN 2/4/2009 Page:4
Servicemaster of the Key City
1845 Washington St. {563}557-1488
Dubuque IA 52001 Fax:{563}557-2507
Fed ID # 421429160
I-a,6„ -I BATHROOM Ceiling Height: 8'
a' --~-~~ T 148.00 SF Walls 21.00 SF Ceiling
N - 169.00 SF Walls & Ceiling 21.00 SF Floor
BI4THROF~~
2.33 SY Flooring 18.50 LF Floor Perimeter
N 18.50 LF Ceil. Perimeter
I- 4' 4" -~
DESCRIPTION
Apply anti-microbial agent
Water extraction from floor -
Category 3 water -Heavy
Clean the floor with pressure steam
Clean the surface area with pressure
steam (walls)*
Tear out wet paneling, bag for
disposal
Tear out wet drywall, cleanup, bag for
disposal
Air mover (per 24 hour period) - 1 x 3
days* QUANTITY
21.00 SF
21.00 SF
21.00 SF
74.00 SF
74.00 SF
74.00 SF
3.00 EA UNIT COST
0.17
1.10
0.61
0.61
0.33
0.55
26.23 RCV
3.57
23.10
12.81
45.14
24.42
40.70
78.69 DEPREC.
(0.00)
(0.00)
(0.00)
(0.00)
(0.00)
(0.00)
(0.00) ACV
3.57
23.10
12.81
45.14
24.42
40.70
78.69
Totals: BATHROOM 228.43 0.00 228.43
Family Room
Family Room
DESCRIPTION QUANTITY UNIT COST RCV DEPREC. ACV
Clean and deodorize carpet 361.00 SF 0.30 108.30 (0.00) 108.30
Clean carpet -cleaning charge per 7.00 EA 4.23 29.61 (0.00) 29.61
step -Heavy
Total: Family Room 137.91 0.00 137.91
LANDING
Roan Heir
/\/'
'
/
Roan Lenph
q ,WNh
SARAZIN 2/4/2009 Page: S
Servicemaster of the Key City
1845 Washington St. {563}557-1488
Dubuque IA 52001 Fax:{563}557-2507
Fed ID # 421429160
DESCRIPTION QUANTITY UNIT COST RCV DEPREC. ACV
Clean floor 81.00 SF 0.28 22.68 (0.00) 22.68
Totals: LANDING 22.68 0.00 22.68
Total: Family Room 160.59 0.00 160.59
~~7~a°s^ HALL Ceiling Height: 8'
~~'~ 164.00 SF Walls 23.56 SF Ceiling
o_ 187.56 SF Walls & Ceiling 23.56 SF Floor
2.62 SY Flooring 20.50 LF Floor Perimeter
20.50 LF Ceil. Perimeter
Missing Wall: 1 - 2'8" X 0'0 " Opens into LAUNDRY Goes to Floor/Ceiling
DESCRIPTION QUANTITY UNIT COST RCV DEPREC. ACV
Apply anti-microbial agent 23.56 SF 0.17 4.01 (0.00) 4.01
Clean the floor with pressure steam 23.56 SF 0.61 14.37 (0.00) 14.37
Clean the surface area with pressure 68.00 SF 0.61 41.48 (0.00) 41.48
steam (walls)*
Tear out wet non-salt'. gluedn. cpt, 23.56 SF 0.73 17.20 (0.00) 17.20
cut/bag -Cat 3 water
Totals: HALL 77.06 0.00 77.06
Total: Main Level 6,651.54 0.00 6,651.54
Line Item Subtotals: SARAZIN 6,651.54 0.00 6,651.54
Adjustments for Base Service Charges Adjustment
Cleaning Remediation Technician 71.38
Total Adjustments for Base Service Charges: 71.38
Line Item Totals: SARAZIN 6,722.92 0.00 6,722.92
SARAZIN 2/4/2009 Page:6
Servicemaster of the Ivey City
1845 Washington St.
Dubuque IA 52001
Fed ID # 421429160
{563}557-1488
Fax:{563}557-2507
Grand Total Areas:
1,706.67 SF Walls
611.53 SF Floor
0.00 SF Long Wall
611.53 SF Ceiling
67.95 SY Flooring
0.00 SF Short Wall
611.53 Floor Area
964.00 Exterior Wall Area
0.00 Surface Area
0.00 Total Ridge Length
667.50 Total Area
120.50 Exterior Perimeter of
Walls
0.00 Number of Squares
0.00 Total Hip Length
2,318.19 SF Walls and Ceiling
213.33 LF Floor Perimeter
213.33 LF Ceil. Perimeter
1,706.67 Interior Wall Area
0.00 Total Perimeter Length
SARAZIN 2/4/2009 Page: ?
Servicemaster of the Ivey City
1845 Washington St. {563}557-1488
Dubuque IA 52001 Fax : {563}557-2507
Fed ID # 421429160
Summary for Dwelling
Line Item Total
Total Adjustments for Base Service Charges
Material Sales Tax @ 7.000% x 578.23
Subtotal
Overhead @ 10.0% x 2,531.50
Profit @ 10.0% x 2,531.50
Clean /Repair Tax @ 7.000% x 5,471.40
Replacement Cost Value
Net Claim
6,651.54
71.38
40.48
6,763.40
253.15
253.15
383.00
$7,652.70
$7,652.70
SARAZIN 2/4/2009 Page: B
Servicemaster of the Key City
1845 Washington St. {563}557-1488
Dubuque IA 52001 Fax:{563}557-2507
Fed ID # 421429160
Recap by Room
Estimate: SARAZIN
Area: Main Level 1,022.12 15.20%
STORAGE 1,944.81 28.93
BEDROOM 520.95 7.75%
LAUNDRY 2,697.58 40.13%
BATHROOM 228.43 3.40%
Area: Family Room 137.91 2.05%
LANDING 22.68 0.34%
Area Subtotal: Family Room 160.59 2.39%
HALL 77.06 1.15%
Area Subtotal: Main Level 6,651.54 98.94%
Subtotal of Areas 6,651.54 98.94%
Base Service Charges 71.38 1.06%
Total 6,722.92 100.00%
SARAZIN 2/4/2009 Page:9
~ervicemaster of the Key City
1845 Washington St. {563}557-1488
Dubuque IA 52001 Fax : {563}557-2507
Fed ID # 421429160
O&P Items
GENERAL DEMOLITION
ELECTRICAL
PLUMBING
TEMPORARY REPAIRS
WATER EXTRACTION & REMEDIATION
Subtotal
Base Service Charges
Material Sales Tax @
Overhead @
Profit @
O&P Items Subtotal
Non-O&P Items
APPLIANCES
CLEANING
CONTENT MANIPULATION
GENERAL DEMOLITION
WATER EXTRACTION & REMEDIATION
Non-O&P Items Subtotal
O&P Items Subtotal
Clean /Repair Tax @
Total
SARAZIN
Recap by Category
7.000%
10.0%
10.0%
7.000%
Total Dollars
458.06 5.99%
225.55 2.95%
1,498.58 19.58%
264.60 3.46%
82.50 1.08%
2,529.29 33.05%
71.38 0.93%
40.48 0.53%
253.15 3.31%
253.15 3.31%
3,147.45 41.13%
Total Dollars
26.82 0.35%
1,020.56 13.34%
356.52 4.66%
424.43 5.55%
2,293.92 29.98%
4,122.25 53.87%
3,147.45 41.13%
383.00 5.00%
7,652.70 100.00%
2/4/2009 Page: 10
Main Level
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SARAZIN 2/4/2009 Page:ll
P.®. BOX 2.312
DUBUQUE, fA 5 1
(563) 583-5080
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