Claim Reuter, JeffCLAIM 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: Jeff Reuter "home" 8990 Old Davenport Rd., Dubq, IA 52003
2. Address: 1645-1645 1/2 Elm St.
`
3. Telephone Number: 582 4316
4. Date of Incident: 9-5-04 & 9-6-04
5. Time of Incident: backed up City sewers
6. Location of Incident (Be specific): 1645 & 1645 1/2 Elm
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.)
City Sewer was plugged - therefore caused sewage to be backed up into house, causing bathroom to overflow, putting approx. l" inch of water on 2 occasions.
8. What were weather conditions like? Nice
9. Give name and address of any witnesses: Merlin Reuter 8376 Old Davenport Rd. & 2 Roto Rooter Plubers (552 1828)
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.)
Damage was to the bathroom due to water overflow
13. What other damages do you claim, if any?
Bill from Roto Rooter
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?
$650.00 replace bathroom floor and charges from Roto Rooter $523.30 totals $1,174.30
16. Why do you claim the City of Dubuque is responsible?
City sewer line was plugged causing tub and toilet to overflow.
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 at Dubuque, Iowa this 13 day of September, 2004.
/s/ Jeff Reuter
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
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CLAIM AGAINST THE CITY OF DUBUQUE;'IOWA «)?, i, ~'I
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This written report constitutes your claim against the City of Dubuque, Iowa. You shoulð' () /
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 WI R WILL NOT BE PAID.
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1. Name of Claimant:
2. Address: "&
3. Telephone Number: ,-~?5 c:< - ¿¡ 3/ro
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4. Date of Incident: 9- '::'-.0 $'" a~ f - t - 0 y
5. Time of Incident: ~ ~~ .
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6. Location of Incident (Be specific): / c/ s ~ I LÇ c¡ 5 2--
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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.) - 0
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ItJWhat were weather conditions like? ~
9. Give name and address of any witnesses: ~t~;? -€¿~~ - ð~ 3 ;; (,:¡ t9---ê-ll
DcVl~ J:M, v¿( J(&:to ?~-u ~<A/ (.5':,j-c:z-/ ?~S-)
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).
1.10
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?
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.)
It) 0
s¡r~ø ~
15. What amount do you claim from the City of Dubuque? (ç::'o. ~
~~d~r ke-t:V K~'-'.S<xtj JoG -' ~ 7l~ I~'f' 30
16. Why do you claim the City of Dubuque is responsible?
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1 . Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name and address.) IV ô
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 /.~ day ofS<!J~rcf~ , 20 0 r¡
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(Print Name)
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(Rev. 1/00 & 7/01)
Locally Owned and Operated
PAUL HERRIG
PLUMBING, INC.
tJ,t!:
ROTO-
r BI!~E!~~.
- SERVICE
. A>td A"'t!lf CJo \ltzou.6Iu '2)0"'" the '2)Mi" . " ,
P.O. Box 1533' Dubuque, Iowa 52004 . Phone 563-552-1828
. TV Camera Inspection & Video Recording
. High Pressure Water Sewer Cleaning. Electric Sewer Cleaning
CUSTOMER'S
ORDER NO.
NAME
¡;> ~ ú'k Þ--
ADDRESS
(.Ç.,t-
.:reF ¡::
<;(37' O¿;I:
It. rrlEL..... .$7)
HERE'S THE PROBLEM I FOUND AND FIXED,
YOUR: WAS CLOGGED BY:
0 sink 0 grease
0 tub or shower 0 food
0 toilet 0 paper or sanitery products
0 laundry I washer lines 0 hair
0 floor drain 0 Unt
0 septic tenk line 0 tree roots
0 main sewer line 0 foreign objects
0 other 0 sludge
0 soap residue
0 other.
TOTAL FOOTAGE CLEANED' KNIVES USED,
JOB DESCRIPTION AND REMARKS:
-- CUSTOMER-SIGNATURE
DATE 16-
20 Oý
¡)A"'t:"_».r R/J
. ,
;;'-)0(1];
CHARGES
.. sink...,..,........,...............,..,..,
tub...................,....,....,....,....
toilet......,............,................
floor drain............................
laundry.................:....,.........
septic line.............,...,....,..,..
main sewer,...........,.........,...,
.1' í'1-~7,(
$....."~,,'( ,.
7 'l Î,c,.o,.
'J.:"'" l-'
OPERATOR SIGNATURE
A service charge of 11/2% per month (18% per annum) will be charged to all accounts past'
30 days, Costs plus reasonable attomey fees to be added in case of su~ for collection.
Locally Owned and Operated
PAUL HERRIG
PLUMBING, INC.
(Joe.
ROTO-
rBø!!~~
- SEavlCE
. A"d A""Hf CJo \[.zou.6les '2)0"'" the '2)Mi" . "
, P.O. Box 1533. Dubuque, Iowa 52004. Phone 563-552-1828
. TV Camera Inspection & Video Recording
. High Pressure Water Sewer Cleaning' Electric Sewer Cleaning
CUSTOMER'S
ORDER NO.
(/(YS .EOm $7) DATE 9/6 20 0'1
~ F ¡: !?pv 1f"J- .£;'l' (, /3
c;?37¿, OLefJ ,a"vP~
NAME
ADDRESS
HERE'S THE PROBLEM I FOUND AND FIXED,
YOUR: WAS CLOGGED BY:
0 'sink 0 grease
0 tub or shower 0 food
0 toilet Q-paper or sanitery products
0 laundry I washer lines 0 hair
0 floor drain 0 lint
0 septic tenk line 0 tree roots
i;l'main sewer line 0 foreign objects
0 other. 0 sludge
0 soap residue
0 other,
CHARGES
sink....,......,...........,..............
tub......................................,
toilet.........,...........,.............,
floor drain......,..........,..........
laundry"..,.....,........,............
septic line............,..........,....$,
mainsewer..........,...............S ;788'
TOTAL FOOTAGE CLEANED' Î!)"; K ~ -1 ' '2, '7 M \-- $ '\ £)
NIVES USED"> ' '"
- ('A« /21ci:: $.
#.,.; _l," $
JOB DESCRiPTION AND REMARKS: Oß """e" .4 r
CS"" F¡.o'" ÍJ.~ Cl.-(',.-,...;f'-
,h.tA""'I../.- ~.r~T..~ i....u~( tll'v/"P-,
, t1.- rJ TOTAL 30'6,
wI!., 1......... <.-~A"""-- C, 'i' ::.""..",.._., IfdófIn=
- / REASEPAYFRCM1HISmn-
,., ¡!.,ç /" 1.."'5 ') ot:'d-tl. ¡) r - ¡
, ,ð7r~"( -f ::;;./ f"UP
CUSTOMER SIGNATURE OPERATOR SIGNATURE' ~8.J
A service charge ot 11/2% pet month (18% per annum) will be ch3lged to all a~
30 days, Costs plus reasonable attorney fees to be added in case of su~ for collection,
\¡VINGER
----
,....Ogt,~~7~~BCYH:')N. INC.
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PROPOSAL
._~[:~-;~~~. ~~-=--
2175 Washington
DubuC¡l;e, ;owa 5200i
PH: (563) 557-7036
FAX: (563) 585-0274
003005
Name: ~W /fu~~ <,
Address! & (I!,~ é 2)'1/ ,.4-7
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