Claim American Trust & SavingsCLAIM 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: American Trust and Savings
2. Address: 855 Main St.
3. Telephone Number: 582 1841
4. Date of Incident: summer 2002
5. Time of Incident:
6. Location of Incident (Be specific):
Alley between Main & Locust, 8th & 9th St.
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.)
Roof water to storm drain backed up in C & B basement, Gus Psihoyos initiated the process.
8. What were weather conditions like?
9. Give name and address of any witnesses:
Gus
10. Did police investigate? (If so, give names of officers.)
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.)
Not to American Trust
13. What other damages do you claim, if any?
N/A
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?
$11664.05
16. Why do you claim the City of Dubuque is responsible?
The City Water Dept. cut and capped storm sewer when installing new water main shut off. Haileng Xiao oversaw the project.
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 4th day of October, 03. , 20 .
/s/ Kevin Goranson
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
CLAIM AGAINST THE CITY OF DUBUI~r0E?IOW-A~ ~-~'~ f~
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: ~,%~,v', ~-~-t '"T-/"o~' ~ ~_~_~
2. Address: ~ ~".~" i/~'~ ~ -~ ~T
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 v~as involve, d, give the
en~loy~ee's n,a_m~)_
8. What were weather conditions like?
9. Give 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).
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, if any?
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? ~ j [ ~, ~, ~ , (D~'
16. Why do you claim the City of Dubuque is responsible?
17. Have you n~ade any claim against anyone else for damages as a result of this incident?
(If yes, give nameand 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
'(Sigr~ature)
(Print Name)
(Rev. 1/00 & 7/01)
Jaeger
17448 S. John Deere Rd,
Dubuque, IA 52001
Phone (319) 583-6677
Fax (319) 583-5495
[ INVOICE t
DATE INVOICE #
9/23/2002 5942
BILL TO:
American Trust
Town Clock Plaza
Dubuque, IA 52001
P.O. NUMBER TERMS PROJECT
Due on receipt
QUANT~Y
20
4
4
1
2
2
1
1
1
1
1
1
1
1
6
3
DESCRIPTION
8" C900 PVC Pipe ~ Foot
8" Mission Band - Clay x Ductile
Thin Rubber Bushing (for Mission Coupling)
4" Cast Iron Clean Out
4" Brass Plug
4" Gasket
6" Clay x Cast Iron Fernco Coupling
6" Clay x 4" Cast Iron Fernco Coupling
6" PVC Tee
6x 4" PVC Bushing
4" PVC 90 Street Ell
4" PVC Female Cleanout
4" PVC Flush Plug
6" PVC 90 Street Ell
6" PVC Pipe ~ Foot
4" PVC Pipe ~ Foot
Hydraulic Cement
Base Stone, Clean Stone & Trucking
RATE
10.00
43.70
22.10
28.93
8.61
3.68
27.42
16.99
AMOUNT
200.00T
I74.80T
88.40T
28.93T
17.22T
7.36T
27.42T
16.99T
Mr. Rooter - Camera Lines & Clean Drains
Tschiggfrie Excavating
Concrete
Black Top Patching & Repair
Backhoe & Operator
Compactor
Dump Truck
45.49 45.49T
15.41 15.41T
4.89 4.89T
4.19 4.19T
3.78 3.78T
34. i8 34.18T
2.52 15.12T
1.95 5.85T
12.12 12.12T
456.00 456.00T
Credit acdounts are due on the 1st of the month. Maximum credit (90)
days, 1 1/2% service charge on all past due accounts.
Paae 1
1,391.21
2,433.72
44.10
1,250.98
520.00
i 00.00
100.00
TOTAL
1;391.21
2,433.72
44.10T
1,250.98T
520.00T
100.00T
100.00T
Jaeger
P~.UMB]NG & PUMP, iNC.
17448 S. John Deere Rd.
Dubuque, IA 52001
Phone (319) 583-6677
Fax (319) 583-5495
INVOICE
DATE INVOICE #
9/23/2002 5942
BILL TO:
American Trust
Town Clock Plaza
Dubuque, IA 52001
EO, NUMBER TERMS PROJECT
Due On receipt
QUANTITY DESCRIPTION RATE AMOUNT
Barricade
Ditch Pump
Cement & Saw blades
Labor
Sales Tax
Credit accounts are due on the 1st of the month. Maximum credit (90)
days, 1 1/2% service charge on ali past due accounts.
Page 2
35.00
25.00
25.00
4,140.00
6.00%
TOTAL
35.00T
25.00
25.00
4,140.00T
440.89
$11,664.05