Claim by Dan and Molly FitzsimmonsMud
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CLAIM AGAINST THE CITY OF DUBUQUE, IOWA V
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 13 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: Dan & Molly Fitzsimmons
2. Address: 515 Fenelon PI
3. Telephone Number 663 - 1115
4. Date of Incident: June 24, 2010
5. Time of Incident: Between 7 AM and 3 PM
6. Location of Incident (Be specific):
515 Fenelon PI - water line enters off of Raymond PI main
8. What were weather conditions like?
NA
10. Did police investigate? (If so, give names of officers.)
No
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.)
Fire hydrant at Raymond and Cooper Places moved, main valve at Raymond and Fenelon PI
failed and main could not be flushed. We were not informed of this situation, and therefore
took no precautions to prevent debris from filling our house lines. As a result, a large amount
of debris made its way to our water heater, shower valve, and drinking water filter system (RO).
9. Give name and address of any witnesses:
Spoke with Paul with water distribution after the fact. Cause and effect seemed very clear.
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.)
Yes, total blockage of 2nd floor bathroo pipes along withshower valve and head. Much
debris also found in water heater and reverse osmosis (RO)filter system. Flushing RO
system and replacing filters did not fix problem. System, which has its own pressure tank,
had to be replaced. Material: $184.11 + Labor:$305 = Total cost: $489.11
13. What other damages do you claim, if any?
none at this time.
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?
$489.11
16. Why do you claim the City of Dubuque is responsible?
Had we been notified of the problem, like all houses on Raymond PI were, we could have
properly flushed our line before unknowingly using various fixtures throughout the house.
Our house number appeared on the map for this line as #515 and there is no 515 Raymond PI
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 this 25 day of
August
Signa ure)
Dan & Molly Fitzsimmons
(Print Name)
,2010
-o
w
rn
m
0
Description
Amount
Flush water heater
55.00
Total blockage in 2nd floor bathroom piping - Repair shower valve and head, and cleared and
backflushed pipes of debris
185.00
Flush reverse - osmosis system and replace filters
65.00
Sensor Services, Inc.
406 E. 7th St.
Suite 2
Dubuque, IA 52001
USA
Voice: 563 -556 -2982
Fax: 563 -583 -0952
Sold To:
Fitzsimmons, Dan & Molly
515 Fenelon PI
Dubuque, IA 52001
Customer ID: Fitzsimmons
Invoice
Invoice Number:
2521
Invoice Date:
6/26/10
Page:
1
Customer PO
Payment Terms
Net 30 Days
Sales Rep ID
Due Date
7/26/10
Check No: 4227
Subtotal
Sales Tax
Total Invoice Amount
Payment Received
TOTAL
305.00
21.35
326.35
326.35
0.00
Farm & Fleet of Platteville
1535 E. Business Highway 151
Platteville, WI 53818 -3844
(608) 348 - 2484
STORE: 00007
CRSHIER: 070010
585028 @ ..... __ 4
Reverse Osmosis System
502402 1 @ 139.99
* ** YOU SAVED 7.24 * **
AMOUNT TENDERED
Discover
ACCT; * * * * * * * * * ** *0002
EXP: * * * * **
APPROVAL: 01741R
2 0 ,
FARM& FLEET
REGISTER: 001
3.79 NT
4.99 NT
139.99 T1F
10.00 T1
1.88 T1
2.50 T1
.95 T1
10.79 T1
r
.25 T1F
SUBTOTAL 181.03
SALES TAX 9.48
TOTAL 190.51
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190.51
TOTAL PAYMENT 190.51
SALES TAX ANALYSIS
CODE RRTE% TAXABLE TAX
T1 5.500 171.00 9.41
NT .000 8.78 .00
T1 5.500 1.25 .07
Transaction: 207108 8/17/2010 3:06 PM
Thank you for shopping at Farm & Fleet
J &RSuppiy
220 Frentress Lake Rd.
East Dubuque, IL. 61025
Ph. 800 - 747 -6501
Fax 815 - 747 -6505
:, = R: 1008744
:USTOMES NO: 0C- CSHACCT
dan fitzsimon3 CASH ACCOUNT
WRITTEN BY: hook
CUSTOMER P.O. SHIP VIA OUR ORDER i TERMS
PICKUP NO TERMS
ITEM NO. DESCRIPTION ORDERED SHIPPED PRICE AMOUNT
24500019006000 01.50x06 Redi Clamp 1.000 0.00 15.95 15.95
24500023806000 02 X 06 REDI CLAMP 1.000 0.00 18.50 18.50
Picked By of
Delivered By: Priced By
Delivery Time: Truck:
Received
By
ORDER DATE: 8/20/2010
SALESPERSON: HSE
NET ORDER:
FREIGHT:
SALES TAX:
ORDER TOTAL:
DELIVERY DATE
34.45
0.00
2.33
36.'78