Claim by Christa Welu TrustCLAIM 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 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: Lf/R -ISTA W w T�, �1 L.�
ST oMl.li�
('tY f t t L) _. _ ` `��
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2. Address: 259 5 v R.tte ,t . y S i s>_ail '
3. Telephone Number: C16 GH lP (Y\ \,? 5 (03 ' Sg I 0041
4. Date of Incident: U1—) Ywt,.)O 1
5. Time of Incident: k.1.1J
6. Location of Incident (Be specific):
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.)
Lars L... f 2.om No«.SF, WAS ►JO's HoCW -A-tf
Li N L "r�SC&7C COQ v col
8. What were weather conditions like?
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9. Give name and address of any witnesses: /Jl
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.)
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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. What other damages do you claim, if any? IA
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? Two Blu_3 PA to
To MQ, Q66i' -... O0c, 'c >r $ 2°■O , • Orve 44- I ' - 1'40. 5%
16. Why do you claim the City of Dubuque is responsible?
THE, LM tmil_. WAS NO Rte.UN\f CXGr, s a TNC
firm L) Utz l' V. ORX-- .
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?
1.4
Dated this day of
, 20
(Signature) CO
CN ��Tfi (J L j<1
(Print Name) -� j�,� tD
(R�aT Cr O MCA) n O r" �. 1 S
: Fiof-)G S B. ; --- ,lLes t o
eS� QtLL5 N.AJt (1 PA ►o. T- fo -- 6 S`4.4
G - FoR $ r130, Zb
Cpoi mut. cry — 1 - 72.44.s+. 0, A .
33$5 14 l fT•oA,a
TDuBUN ', Z SZ.Q!
TOTAL --
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P.O. Box 1312
Dubuque, IA 52001 -1 31 2
563.583.5080
CONTRACT / RETAIL INSTALLMENT
No 24-7- a)77
START DATE: 13 / 1 / (i END DATE: / /
JOB ADDRESS
BILLING ADDRESS IF DIFFERENT
SERVICE ORDER
TYPE
Customer Name
}
Address
c 4-C.
City
1 St. i 'Zip ` 7 Job Phone
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E -mail
Address:
Would )Sou like to receive
E -mail offers? ❑ Yes
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•
•
Never an overtime charge!
24 Hours a Day • 7 Days a Week
www.MrRooter.com
Jndependently owned & operated.
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Customer Name
Address
City
Technician(s) .�
Authorized Signature X
St.
Zip
PAYMENT
❑ Cash heck ❑ Billed
VISA r
Ame an Iixpress Check # or Credit card referral #: q ( j
Auth Code:
.esidential ❑ Commercial
DIAGNOSIS
SERVICE AUTHORIZATION
Contact Person
Other Phone
re -
I agree that initial price quoted prior to start of work does not include any additional or unforeseen tasks. Nor materials which may be found to be necessary to
complete repairs or replacements. I also agree to hold Mr. Rooted or its assigns harmless for parts deemed corroded, unusable or unreliable for completion
of stated work to be done. I hereby authorize Mr. Rooter to perform proposed work and agree to all agreement conditions as displayed on the face and reverse
sides of this document and further acknowledge that this invoice is due upon receipt. Irependently owned and operated franchise.
TASK # WARRANTY
DESCRIPTION OF PRODUCTS AND SERVICES
APPROVAL
INITIAL
STANDARD
RATE
MEMBER
RATE
YOU SAVE
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Technician Signature X
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❑ Approved ❑ Declined
❑ Approved ❑ Declined
Acceptance bf work + performed: I find the servic and m at e rial s p rformed & installed have been completed in accordance with this
agreement. I agree to pay reasonable attorney fees, collection fees and court"cpsts in the event of legal action pursuant to collection
of amount due. , r !
Customer Signature X , t. _._- !'/c.. -e. -s - / „ "
/❑Approved ❑ Declined /
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I do hereby state that the above work has been done in a workmanlike manner and to applicable codes.
Truck #
CUSTOMER COP
`T u
SUB T OTAL
TOTAL
TAX
, ;(,Servtce ❑ Prev Maint ❑ Opportunity Call
Li Advantage Plan Member ❑ Estimate
wner ❑ Tenant
$ 7 _ / ?
f - \( 2
L (.
$
RECOMMENDATIONS
SAVE MONEY WITH OUR ADVANTAGE PLANTM!
Advantage
Plan
$
$
PLUMBING CHECK -UP
Customer Name:
WATER PRESSURE READINGS
Time of Reading ❑ AM LIPM
PRV PSI
BATHROOM PASS FAIL
Sink - Drainage ❑ ❑
Faucet ❑ ❑
Trap ❑ ❑
E.S.O. Valves ❑ ❑
Shower - Drainage ❑ ❑
Faucet / Diverter Li Li
Anti -Scald Valve ❑ ❑
E.S.O. Valves ❑ ❑
Tub- Drainage ❑ ❑
Faucet / Diverter ❑ ❑
E.S.O. Valves ❑ ❑
Toilet - Operations ❑ Li
E.S.O. Valves ❑ ❑
BATHROOM PASS
Sink - Drainage ❑
Faucet ❑
Trap
E.S.O. Valves
Shower - Drainage
Faucet / Diverter
Anti -Scald Valve
E.S.O. Valves
Tub - Drainage
Faucet / Diverter
E.S.O. Valves
Toilet - Operations
E.S.O. Valves
Hot water PSI
❑ Gas ❑ Electric
Brand
Date of manufacture
Gallons
WATER HEATER
❑ Propane
T & P Valve
Water Supply
Tank
Boiler Drain
Expansion Tank
Timer
J BTU
PASS FAIL
J
J J
J J
J ❑
J
❑ J
Hydronic Heating ❑ P ❑ F
OTHER
COMMENTS/ RECOMMENDATIONS
I understand this inspection is performed with the intent to expose all possible
plumbing problems but by no means carries any guarantee Neither Mr Rooter, any
entity associated with Mr Rooter, nor the service technician performing this inspection
shall be liable for any damages which may arise from an identified or unidentified
plumbing problem, but shall be the sole responsibility of the property owner
X
Customer Signature
KITCHEN PASS FAIL
Kit. Sink - Drainage U J
Faucet / Sprayer ❑ J
Basket Strainer ❑ J
Rim Leakage J J
Cont. Waste & Trap J J
Air -gap ❑ J
E.S.O. Valves J J
Disposer J _J
Water Filter ❑ J
LAUNDRY PASS
Sink - Drainage ❑
Faucet J
Trap
E.S.O. Valves ❑
Wash Mach. - Drain J
Hoses - Cold ❑
Hoses - Hot U
OUTSIDE PASS FAIL
Meter Inspection ❑ J
Faucet J J
Faucet J J
Faucet ❑ J
Anti - Siphon J J
Lawn Sprinkler Sys. '❑ J
Clean Out ❑ J
Video Inspection JY J N
)b Phone
1 • • • 1 1
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P.O. Box 1312
Dubuque, IA 52001 -1 31 2
563.583.5080
BILLING ADDRESS IF DIFFERENT
SERVICE AUTHORIZATION
a �
rr
SERVICE ORDER
TYPE
Customer Name
Address
City
Technician(s)
Expre s Check # or Credit card referral #:
I agree that initial price quoted prior to start of work does not include any additional or unforeseen tasks. Nor materials which may be found to be necessary to
complete repairs or replacements. I also agree to hold Mr. Rootel® or its assigns harmless for parts deemed corroded, unusable or unreliable for completion
of stated work to be done. I hereby authorize Mr. Rooter to perform proposed work and agree to all agreement conditions as displayed on the face and reverse
sides of this document and further acknowletje that this invoice is due / upon r Irrependently owned and operated franchise.
A
INITIAL RATE RATE
YOU SAVE
Authorized Signature X
4jill
r'Y /
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V
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St.
Contact Person
5 AI
fill ;'' ,(1
SAVE MONEY WITH OUR ADVANTAGE PLANTM!
Zip
tature X f)c .L._ ,
that the above work has been done in a workmanlike manner and to applicable codes.
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r
Other Phone
at.
Auth Code:
r2) ! ?rt /`r" c
A
- l'cihr
kJ Approved ❑ Declined
❑ Approved ❑ Declined
❑ Approved ❑ Declined
/
y. rk'performed: I find the s ervice and materials p &rformed & installed have been completed in accordance with this
e to pay reasonable attorney fees, collection fees and court,cpsts in the event of legal action pursuant to collection
117e . 1 Truck #
CUSTOMER COP
CONTRACT / RETAIL INSTALLMENT
14 2 2-4-
START DATE:
`1 Lf
^t
Advantage
Plan
:
/
1/ i (• END DATE: / /
,].Servtce J Prev Maint ❑ Opportunity Call
❑Advantage Plan Member ❑ Estimate
owner ❑ Tenant
110'3
ksidential ❑ Commercial
$ 7 7 / ?
7 5
PLUMBING CHECK -UP
Customer Name:
WATER PRESSURE READINGS
Time of Reading JAM _J PM
PRV PSI
BATHROOM PASS FAIL
Sink - Drainage ❑ ❑
Faucet ❑ ❑
Trap ❑ ❑
E.S.O. Valves ❑ ❑
Shower - Drainage ❑ U
Faucet / Diverter ❑ ❑
Anti -Scald Valve ❑ ❑
E.S.O. Valves ❑ ❑
Tub- Drainage ❑ ❑
Faucet / Diverter ❑ ❑
E.S.O. Valves ❑ ❑
Toilet - Operations ❑ ❑
E.S.O. Valves J Li
BATHROOM PASS FAIL
Sink - Drainage ❑ J
Faucet ❑ ❑
Trap ❑ ❑
E.S.O. Valves ❑ ❑
Shower - Drainage ❑ ❑
Faucet / Diverter ❑ ❑
Anti -Scald Valve ❑ ❑
E.S.O. Valves ❑ ❑
Tub - Drainage ❑ ❑
Faucet / Diverter ❑ ❑
E.S.O. Valves ❑ ❑
Toilet - Operations ❑ ❑
E.S.O. Valves ❑ ❑
❑ Gas
Hot water PSI
Brand
Date of manufacture
Gallons
WATER HEATER
❑ Electric ❑ Propane J BTU
PASS FAIL
T & P Valve ❑
Water Supply J J
Tank J J
Boiler Drain _J J
Expansion Tank J J
Timer J J
Hydronic Heating ❑ P ❑ F
OTHER
COMMENTS/ RECOMMENDATIONS
r`
KITCHEN PASS FAIL
Kit. Sink - Drainage J J
Faucet / Sprayer J J
Basket Strainer J J
Rim Leakage J J
Cont. Waste & Trap J J
Air -gap J J
E.S.O. Valves J J
Disposer J 1
Water Filter J J
LAUNDRY PASS `A'
Sink - Drainage ❑ J
Faucet J J
Trap J J
E.S.O. Valves ❑ J
Wash Mach. - Drain U J
Hoses - Cold ❑ J
Hoses - Hot U J
OUTSIDE PASS FAIL
Meter Inspection ❑ J
Faucet J J
Faucet J J
Faucet J J
Anti - Siphon J J
Lawn Sprinkler Sys. J J
Clean Out ❑ 1
Video Inspection JY J N
I understand this inspection is performed with the intent to expose all possible
plumbing problems but by no means carries any guarantee Neither Mr Rooter any
entity associated with Mr Rooter, nor the service technician performing this inspection
shall be liable for any damages which may arise from an identified or unidentified
plumbing problem, but shall be the sole responsibility of the property owner
X
Customer Signature
J