Claim Leibold, MelvinCLAIM 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: Melvin Leibold
2. Address: 93 Nevada St., Dubuque IA 52001
3. Telephone Number: (563) 583 8717
4. Date of Incident: April 8, 2003
5. Time of Incident: 9:30 a.m.
6. Location of Incident (Be specific):
Basement of home at 93 Nevada 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.)
Two inches of sewage water in basement due to sewage back up.
8. What were weather conditions like?
Normal with melting snow from snow on 4 7 03
9. Give name and address of any witnesses:
City sewage maintenance employees' John Klosterman (Sewer Maintenance Super.); also checked on sewer blockage due to mineral deposit buildup.
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.)
Basement carpeting water soaked - Furniture standing in 2 inches of water. Items stored in boxes; water soaked and items destroyed.
Kanndo professional services contacted to pump water from basement and deoderize. (See attached sheet)
13. What other damages do you claim, if any?
Not claiming our time and effort of vacuuming water up until Kanndo arrived.
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? $238.50
16. Why do you claim the City of Dubuque is responsible?
Failure of pproper maintenance of sewer system. Causing excessive buildup of minteral deposits leading to blockage.
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?
No
Dated at Dubuque, Iowa this 22nd day of April , 2003.
/s/Melvin Leibold
(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. 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 Teport 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 ~ITY 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= ~ ~L ~ v, ~-x )_J ~ , 'XO o ~. 'NC~.
:3. Telephone Number:
4. Date of Incident:
$
5. Time of Incident: ~ 3'''~ ~-
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? ~'~--~.~ ~.o-~),'~ ~=~-~ ~>= ~
nesses: ~ '~D
9. Give name and address of ~nywJt~. 5~--~ ~, ~ ~ ~--~ ~
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 andthe extent ~ r. Yama~e~..
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?
16. Why do yOu claim the City of Dubuque is responsible? /L-~,~,~.w_~ c,~r k~o -~
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? .?~o
Dated at Dubuque, Iowa this
.2, _b~ ~,~day of
~ (signaturei
(Print Name)
(Rev. 1/00 & 7/01)
(563) 556-6168
1-800-886-6168
Fax: (563) 556-4680
email: kanndoincdbq@aoI, cors
950 MAIN STREET - DUBUQUE, IA 52001
CARPET CLEANING
Room Size Sq. Ft. Amount
KITCHEN
DINING
LIVING
HALL
STEPS
BEDROOM
BEDROOM
BEDROOM
BEDROOM
FAMILY
BASEMENT
[] Vacuum to remove embedded soil from carpet fibers
[] Apply pis-spray and deodorizer to loosen dirt from fiber
[] Steam clean w/RX20 rotary steam extractor
AN AMAZING CARPET CLEANING BREAKTHROUGH
[] Groom carpets to set pile for efficient and uniform appearance
[] Heat Transfer
[] Treat spots as needed
[] Move and block up furniture as needed
CARPET CLEANING
CARPET PROTECTOR
CARPET CLEANING & PROTECTOR TOTAL
UPHOLSTERY CLEANING
PIECE DESCRIPTION AMOUNT
UPHOLSTERY CLEANING
FABRIC PROTECTOR
CLEANING UPHOLSTERY & PROTECTOR TOTAL
AIR DUCT CLEANING
[] Remove registers and hand wipe
[] Air wash all ductwork
[] Wipe down interior & exterior of furnace
[] Re-install registers.
Client Name:
Address:
City ~'~(~ State
Job Address
Contact:.
JobPhone: ~'3- !f-~/ 7
E-mail Address:.
Other Phone:
~Je??'3 Rate: z~- ~g~'- ,~ Estimate:
[---] Cash ~ MasterCard Card# "~'~
~---] Check F-~ ViSA Expires
Total amount due upon completion of services. A finance charge of 1.5% which is an
annual percentage rate of 18%, will be charged on the amount of this invoice starting 30
days after the invoice date.
OTHER
KANNDO Professional Services wants to serve you better. Please read the
following consumer awareness information and initial it.
When was the last time your carpet was cleaned?_
How was it cleaned?.
Alert technicians of liquid spills because we may have to use a process
to prevent wicking.
Carpet Cleaning
Please move small items, knick knacks, antiques, breakables, etc.
For ideal drying conditions: set your thermostat at 72', use fans and
dehumidifiers, especially in basements.
Please leave blocks or plastic sheets under furniture for 24 hours or until dry.
The KANNETO method of cleaning carpets will deodorize & sanitize
your carpet.
We cannot repair worn fibers through cleaning.
Cleaning will not repair color loss due to fading, chemical damage, pet stains
or any other permanent stains or color changes due to BHT, and / or
foreign materials embedded in carpet that may wick up and cause red,
blue, green, yellow, etc. spots.
Upholstery Cleaning
Due to the unpredictable nature of upholstery fabrics and dyes, KANNDO
makes no representations or warranties regarding the upholstery
cleaning to be performed.
Take caution when coming off ef wet carpet to hard surfaces...
slippery when wet.
By initialing where indicated below, the client acknowledges that
client assumes all risk associated with the cleaning and hereby
releases KANNDO from any and all loss, damage, or expense sustained
by client as a result of the cleaning,
Payment due upon completion of the job. THANK YOU!
I have read and understand the above and have received complimentary
Avenge and Spotting Char[
DRYER VENT TOTAL
AIR DUCT CLEANING TOTAL
ENVIROCON TOTAL
AIR DUCT & ENVIROCON TOTAl
Thank you for calling KANNDO Professional Services ..
SUBTOTA
GRAND TOTAL
100% Guarantee